ITL  B.HOEBERII 

EDICAL  BOO 

ithSt 


•is  'O* 


Columbia  mnimm  '^\^ 


3^ef  erence  %ihvavv 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlespracti1913dudl 


A  vesico- 
vaginal: 


STUDY    FROM    NUMEROUS   DISSECTIONS   AND   PLATES. 


THE 


'(;)\'! 


PRINCIPLES  AND  PEACTICE 


OP 


GYNECOLOGY 


FOE  STUDENTS  AND  PEACTITIONEES 


BY 

E.  C.  DUDLEY,  A.M.,  M.D. 

EX-PRESIDENT     OF    THE     AMERICAN     GTNECOLOGICAL     SOCIETY;     PROFESSOR     OF     GYNECOLOGY,    NORTH- 
WESTERN  UNIVERSITY    MEDICAL    SCHOOL;    GYNECOLOGIST    TO    ST.    LUKE's   HOSPITAL,    CHICAGO" 
EX-PRESIDENT  OP  THE  CHICAGO  GYNECOLOGICAL  SOCIETY;    ONE  OF  THE  FOUNDERS  OP 
CONGR^S  PERIODIQUE  INTERNATIONAL  DB  GYNECOLOGIE  ET  D'OBSTETRIQUE  ; 
FELLOW  OP  THE  ROYAL  SOCIETY  OP  MEDICINE,  ENGLAND;  SURGEON 
IN    THE    MEDICAL    RESERVE    CORPS,  UNITED   STATES  ARMY 


SIXTH  REVISED  EDITION 


WITH    439    ILLUSTRATIONS    AND    24    FULL-PAGE    PLATES    IN 
COLORS    AND    MONOCHROME 


LEA    &    FEBIGER 

PHILADELPHIA    AND     NEW     YORK 
1913 


Entered  according  to  the  Act  of  Congress,  in  the  year  1913,  by 

LEA  &  FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


TO 

MY  FRIEXD 

FREDERICK  CHEEVER  SHATTUCK 


"This  subject  of  man's  body  is  of  all  other  things  in 
nature  most  susceptible  of  remedy;  but  then  that  remedy 
is  most  susceptible  of  error.  For  the  same  subtility  of  the 
subject  doth  cause  large  possibility  and  easy  failing;  and 
therefore  the  inquiry  ought  to  be  the  more  exact." 

Francis  Bacon,  in  the  Second  Booh  of  the  Proficience  aiid 
Advancement  of  Learning. 


PREFACE 


In  the  effort  to  make  a  thorough-going  revision,  which  should  express 
the  recent  advances  in  Gynecology,  I  have  subjected  the  greater  part 
of  the  book,  paragraph  by  paragraph,  to  a  regional  and  interstitial 
dissection,  have  rewritten  many  chapters,  particularly  on  General 
Principles,  Inflammations,  Tumors,  and  Traumatisms,  and  in  so  doing, 
by  rigid  rearrangement  and  condensation,  have  found  space  for  much 
new  matter  without  enlarging  the  volume. 

In  accordance  with  the  plan  of  the  book  as  set  forth  in  the  prefaces 
to  former  editions  I  have  arranged  the  subjects  in  pathological  and 
etiological  sequence.  For  example,  infections  and  inflammations  are 
brought  together,  so  that  vulvovaginitis,  metritis,  salpingitis,  ovaritis, 
and  peritonitis  may  be  studied  in  the  combined  forms  which  frequently 
they  assume.  *  In  like  manner,  tumors  are  treated  in  another  part, 
traumatisms  in  another,  and  displacements  in  another.  Under  this 
plan  the  student  will  have  constantly  before  him  the  physiological 
and  pathological  unity  of  the  reproductive  system;  on  the  other  hand, 
if  he  considered  all  the  diseases  of  each  organ  in  a  chapter  itself,  he 
would  find  tumors,  traumatisms,  displacements,  and  other  anomalies 
thrown  in  between  the  infections  of  that  organ  and  causal  or  resultant 
infections  in  other  parts  of  the  pelvis,  and  thus  might  lose  sight  of 
the  correlation  of  like  morbid  processes  to  one  another. 

Twenty-eight  illustrations  and  plates  have  been  added  to  explain 
operative  procedures  which  are  set  forth  as  they  take  place  step  by 
step,  in  numerous  series  of  drawings;  for  example,  twenty -two  draw- 
ings describe  the  steps  of  the  different  operations  of  Myomectomy 
and  Hysteromyomectomy ;  twenty-five  explain  Perineal  Lacerations 
and  the  steps  of  Perineorrhaphy. 

I  am  indebted  for  valuable  assistance  in  the  parts  on  General 
Principles  and  Inflammations  to  Dr.  Eugene  S.  Talbot,  Jr.;  for 
numerous  practical  suggestions  to  Drs.  Arthur  Curtis,  Robert  T. 
Gillmore,  and  H.  ]M.  Stowe,  who  have  used  the  book  in  recitation 
work;  for  research  into  recent  literature  to  Dr.  George  H.  Coburn, 
and  for  critical  reading  of  proof  to  Dr.  N.  Sproat  Heaney. 


122  South  Michigan  Boulevard, 
Chicago,  III.,  U.  S.  A. 


E.  C.  D. 


(ni) 


CONTENTS 

PART   I 

GENERAL  PRINCIPLES 

IXTRODCCTIOX 17 

CHAPTER    I 
The  Physiological  Periods  in  the  Life  of  Womax 21 

CHAPTER    II 
Septic  Infection  .\xd  Aseptic  Technique  .'....,....       32 

CH.\PTER   III 
Diagnosis 50 

CBL\PTER   IV 
Local  Treatment 90 

CHAPTER   V 
Minor  Operations 99 

CHAPTER   VI 
Major  Operations 121 

CHAPTER   VII 
Drainage  in  }^Iajor  Operations 142 

CHAPTER   VIII 
After-treatment  in  Major  Operations 152 

CHAPTER   IX 

The  Relations  of  Dress  to  the  Diseases  of  Women 164 

(ix) 


X  CONTENTS 


PART   II 


INFECTIONS,  INFLAMMATIONS,  AND  ALLIED 
DISORDERS 


CHAPTER   X 

General    Considerations    of    Infection    and    Inflammation     op    the 

Reproductive  Organs 169 


CHAPTER  XI 
Vulvitis,  Vulvovaginitis,  Vaginitis 177 

CHAPTER  XII 

Eczema  Vulv^,   Herpes  Vulv^,   Kraurosis  Vulv^,   Pruritus  Vulvae, 

Hyperesthesia  Vulve,  Vaginismus 197 

CHAPTER   XIII 
Metritis — Inflammation  of  the  Uterus 207 

CHAPTER  XIV 
Acute  Metritis 211 

CHAPTER  XV 
Chronic  Endocervicitis 218 

CHAPTER  XVI 
Chronic  Endometritis 226 

CHAPTER  XVII 

Chronic  Metritis •      •     248 

CHAPTER  XVIII 
Salpingitis 255 

CHAPTER  XIX 

Associated    Lesions    of    Salpingitis — Pelvic    Cellulitis,  Pelvic   Peri- 
tonitis, AND  Ovaritis         . 268 


CONTENTS  xi 


CHAPTER  XX 


Treatment   of   Pelvic   Inflammation — Salpingitis,    Pelvic   Cellulitis, 

Pelvic  Peiutonitis,  and  Ovaritis 280 


CHAPTER    XXI 

Urethritis — Urethritis  Complicated   by   Prolapse  of   Urethra — Ure 

thritis  Complicated  by  Suburethral  Abscess — Cystitis — Pyelitis    326 


PART  III 

TUMORS,  TUBAL  PREGXAXCY,  MALFORMATIONS 

CHAPTER   XXII 

TUAIORS    OF   THE    VuLVA   AND    VaGIXA 349 

CHAPTER   XXIII 

Tumors  of  the  Uterus  (Myoma) ■   .      .      .     358 

CHAPTER   XXI^' 
Tumors  of  the  Uterus  (Treatment  of  My'oma) 372 

CHAPTER   XXV 
Tumors  of  the  Uterus  (Carcinoma) 403 

CHAPTER   XXVI 
TuiiORS  OF  the  Uterus  (Sarcoma) 422 

CHAPTER  XXVII 
Tumors  of  the  Uterus  (Deciduoma  Malignum) 425 

CHAPTER   XXVIII 
Solid  Tu^iors  of  the  Ovary 427 

CHAPTER   XXIX 

Ovarian  and  Parovarian  Cysts 429 


xii  CONTENTS 

CHAPTER   XXX 
Ovariotomy 457 

CHAPTER  XXXI 

TtnviORS  OF  THE  Fallopian  Tubes,  Broad  Ligaments,  Round  Ligaments, 

AND  Urinary  Organs 464 

CHAPTER  XXXII 

Ectopic  Pregnancy — Extra-uterine  Pregnancy — Ovarian  Pregnancy — 

Tubal  Pregnancy 469 

CHAPTER  XXXIII 

Embryology  of  the  Genitalia  and  Congenital  Malformations       .      .     486 

CHAPTER  XXXIV 

Congenital  Gynatresia  with  Retained  Menstrual  Fluid      ....      513 


PART  IV 

TRAUMATISMS 

CHAPTER  XXXV 

Injuries  of  the  Vulva  and  Vagina 521 

CHAPTER  XXXVI 

Puerperal  Laceration  of  the  Cervix  Uteri 546 

CHAPTER  XXXVII 
Genital  Fistula 572 


CONTENTS  Xlll 


PART  V 

DISPLACEMENTS  OF  THE  UTERUS  AND  OTHER  PELVIC 

ORGANS 


CHAPTER  XXXVIII 

Displacements  of  the  Uterus 607 

CHAPTER  XXXIX 

Mal-locations  of  the  Uterus 615 

CHAPTER   XL 

Malpositions  of  the  Uterus;  Etiology,  Syjiptoms,  Course,  Diagnosis, 

AND  Prognosis  of  Retroversion  and  Retroflexion     ...  648 

CHAPTER   XLI 

Treatment  of  Retroversion  and  Retroflexion 655 

CHAPTER   XLII 

Anteversion  and  Anteflexion  of  the  Uterus:    Torsion  of  the  Uterus     687 

CHAPTER  XLIII 

In^^ersion  OF  THE  Uterus — Hernia  of  the  Uterus  and  Ovary     .      .      .      .711 


PART  VI 


DISORDERS  OF  ^lENSTRUATION  AND  STERILITY  AND 
INCONTINENCE  OF  URINE 


CHAPTER  XLIV 
Premature  Menstruation  and  Protracted  Menstruation     ....     729 

CHAPTER  XLV 

Amenorrhcea  and  Scanty  Menstruation 731 


xiv  CONTENTS 

CHAPTER  XLVI 

Uterine  Hemorrhage — Menorrhagia  and  Metrorrhagia 736 

CHAPTER  XLVII 
Dysmenorrhcea  and  Periodic  Intermenstrual  Pain       ......     743 

CHAPTER  XLVIII 
Sterility 750 

CHAPTER  XLIX 
Incontinence  of  Urine  in  Women 758 


PRINCIPLES  AND  PRACTICE  OF 
GYNECOLOGY 


INTRODUCTION  1 

The  general  law  that  progress  in  any  direction  is  characterized  by- 
specialization,  with  its  attendant  classification  and  simplicity,  has 
been  exemplified  in  no  great  movement  more  strongly  than  in  the  devel- 
opment of  scientific  medicine  during  the  last  three  decades.  The 
late  Samuel  D.  Gross,  foremost  general  surgeon  of  his  day,  after  a 
long  period  of  active  service  as  author,  teacher,  and  practitioner, 
writing  the  preface  to  the  sixth  edition  of  his  System  of  Surgery  in 
October,  1882,  thus  early  gives  credit  to  specialization  for  the  unpar- 
alleled advances  in  modern  surgery.  Specialization,  he  says  in  sub- 
stance, has  penetrated  with  its  methods  and  instruments  of  research 
the  innermost  recesses  of  the  human  body,  and  in  a  comparatively 
brief  period  has  achieved  triumphs  which  general  surgery  perhaps 
never  would  have  accomplished. 

In  the  earlier  period,  when  the  specialist  confined  himself  to  a  par- 
ticular organ,  disregarding  its  relation  to  the  general  system,  when 
frequently  exclusive  books  appeared  from  this  author,  for  example, 
on  the  stomach,  or  from  that  one  on  the  brain,  specialization  was 
cumbersome,  narrow,  ineffective,  and  a  hindrance  to  scientific  medicine. 
Finally,  the  logical  tendency  to  study  each  part,  not  by  itself,  but  in 
its  essential  relations  to  the  wdiole  system,  gave  rise  to  such  a  welding 
together  into  a  great  unit  of  all  the  specialties  that  any  organ,  even 
though  recognized  in  its  individual  importance  and  autonomy,  at  the 
same  time  was  equally  recognized  as  subject  to  general  law.  It  then 
became  apparent  that  physiological  and  pathological  processes,  such 
as  circulation  and  infection,  were  substantially  the  same  whatever  the 
organ  involved.  Order  then  came  out  of  chaos  and  specialization 
became  a  potent  factor  in  the  simplification  and  progress  of  medicine. 
From  this  time  forward,  laryngology,  rhinology,  orthopedics,  ophthal- 
mology, neurology,  climatology,  state  medicine,  obstetrics,  and  gyne- 
cology rapidly  de^•eloped  and  became  identified  in  all  parts  of  the 
ci^•ilized  world  with  remarkable  groups  of  men  who  have  strengthened 

__  '  From    the    author's    presidential    address,    delivered    at    the    annual    meeting    of    the    American 
Gynecological   Society  at  Niagara  Falls,  1905. 

2  •  (17) 


18  PRINCIPLES  AND  PRACTICE 

scientific  medicine  by  building  up  these  departments  to  an  extent 
unequaled  in  any  other  period  of  history. 

In  nearly  all  the  medical  teaching  centres  of  America  and  Europe 
the  most  conspicuous  specialty  of  modern  medicine,  gynecology,  has 
enjoyed  full  recognition  not  only  in  the  day  of  its  early  struggle,  but 
later  in  the  period  of  its  highest  development,  with  the  significant 
result  that  in  dignity  of  position  and  in  output  of  scientific  product  it 
has  in  many  respects  outbalanced  the  department  of  general  surgery 
itself. 

The  progress  of  gynecology  has  been  marked  by  two  pronounced 
periods :  The  first  was  an  earlier  period,  characterized  by  great  activity 
in  the  perfection  of  numerous  plastic  operations  on  the  vaginal  side 
of  the  pelvic  floor.  This  development  of  minor  plastic  surgery  calls 
to  mind  many  familiar  names  at  home  and  abroad,  most  conspicuous 
among  them  the  names  of  two  pioneers,  Emmet  and  Marion  Sims. 
The  second  or  later  period  was  one  of  tremendous  progress  in  the 
surgery  of  the  obverse  abdominal  side  of  the  pelvic  floor.  Now  a  third 
period  is  before  us  in  which  gynecology  has  taken  to  itself  the  whole 
field  of  abdominal  surgery. 

The  early  gynecologist  was  logically  led  by  the  anatomical,  physio- 
logical, and  pathological  unity  of  the  productive  organs  into  the  peri- 
toneal surgery  of  the  pelvic  cavity  and  thence  by  anatomical  continuity 
into  that  of  the  upper  abdomen.  In  peritoneal  surgery,  his  educated 
touch,  his  special  surgical  judgment,  and,  above  all,  his  training  in 
the  technique  of  plastic  gynecology,  placed  him  on  a  decided  vantage 
ground  over  the  general  surgeon. 

This  widening  of  limitations  to  include  the  territory  of  abdominal 
surgery  has  given  rise  to  an  extraordinary  and  altogether  interesting 
effort  on  the  part  of  the  general  surgeon  to  promulgate  the  erroneous 
idea  that  the  gynecologist  has  become  a  general  surgeon  and  thereby 
has  forced  gynecology  as  a  specialty  into  the  background,  where  any- 
one, even  without  special  preparation  may  practice  it.  Thus  we  hear 
of  "The  Merging  of  Gynecology  into  General  Surgery,"  "The  Passing 
of  a  Great  Specialty,"  "The  Expansion  or  Obliteration  of  a  Specialty." 
We  are  told  that  gynecology  is  a  finished  subject,  and  that  "he  who 
runs  may  read;"  that  it  is  only  a  matter  of  a  few  operative  procedures: 
that  the  technique  of  it  is  now  perfected  and  ready-made  for  the 
hand  of  anyone;  that  soon  in  medical  journals,  in  text-books,  in  medical 
schools,  in  societies  and  hospitals,  gynecology  will  be  merged  into 
general  surgery  and  the  name  will  be  forgotten. 

In  considering  this  most  recent  attitude  toward  gynecology  I  do  not 
refer  to  the  practitioner  who  may  be  so  situated  that  the  most  com- 
petent experts  are  not  available;  necessarily  he  may  be  compelled,  to 
the  best  of  his  ability,  not  for  himself  alone,  but  in  the  interest  of  his 
patient,  to  undertake  not  only  gynecology,  but  all  the  other  specialties; 
nor  do  I  deny  that  a  general  surgeon  of  sufficient  versatility  may 
carry  on  miscellaneous  surgical  work,  and  at  the  same  time,  if  he  will, 
undergo  the    necessary  long   and    careful  training,  may  acquire   the 


INTRODUCTION  19 

special  judjimont,  tlie  special  diaj^iiostic  and  operative  technique,  essen- 
tial to  proficiency  in  the  practice  of  a  great  specialty;  hut  this  admis- 
sion does  not  weaken  the  indictment  which  I  would  ofl'er  against  a  tyi>e 
of  general  surgeon,  whose  number  increases  day  hy  day,  whose  relation 
to  this  sjH'cialty  is  the  outcome  of  a  reasoning  all  his  own,  a  reasoning 
from  the  plausible  premise  that  "the  gynecologist,  having  perfected  and 
simplified  his  specialty,  has  found  it  too  narrow  and  has  expanded"  to 
the  specious  conclusion  that  gynecology  is  an  insignificant  branch  and 
that  the  gynecologist  therefore  has  undertaken  general  surgery.  'J'his 
logic  gives  rise  to  a  sophistry:  if  the  gynecologist  is  a  general  surgeon, 
conversely  the  general  surgeon  is  a  gynecologist.  As  the  times  change 
and  we  change  with  them,  this  type  of  universal  operator,  quick  to  seize 
on  and  turn  to  his  own  account  the  intimation  that  this  specialty  has 
passed,  with  refinement  neither  of  diagnostic  nor  operative  technique, 
with  no  appreciation  of  his  limitations,  hypnotized  by  an  apprentice- 
ship of  six  weeks  in  some  post-graduate  school,  or  by  no  apprenticeship 
at  all,  emboldened  by  the  fact  that  no  one  has  called  him  to  account, 
would  make  gynecology  crude  and  common,  would  persuade  the  public 
and  the  profession  that  it  is  a  mere  caudal  appendix  to  surgery  on 
which  no  one  fears  to  tread.  Let  us  for  the  moment  dismiss  the  general 
discussion  of  the  subject  and  imagine  a  private  hospital  conducted 
under  certain  practical  conditions  of  business  management  and  -pro- 
motion, with  a  year  of  active  practice  in  capital  operations,  most  of 
them  belonging  to  this,  forsooth,  insignificant  branch  of  surgery  and  a 
mortality  of  70  per  cent.,  and  then  with  this  experience  as  a  background, 
going  on  for  an  additional  few  weeks  to  eleven  more  consecuti^•e  ab- 
dominal operations  and  100  per  cent,  of  mortality.  This  is  an  extreme 
but  nevertheless  historical  example,  taken  not  from  the  dark  ages  of 
surgery,  but  from  our  own  times.  It  would  be  painful  to  expose  other 
instances,  but  perhaps  pertinent  to  add  that  excessive  mortality  is  not 
the  only  evil  result  of  defective  operating. 

Gynecology  has  not  passed.  We  are  not  general  surgeons.  We 
are  specialists  in  the  diseases  of  women,  and  as  our  later  transactions 
abundantly  show,  we  are  to  a  rapidly  increasing  extent  specialists  also 
in  the  wider  field  of  abdominal  surgery,  a  field  in  which  the  account 
on  the  ledger  as  it  stands  to-day  wall  show  general  surgery  indebted 
to  us  for  a  great  part  of  its  practical  and  scientific  progress;  the  claim 
is  valid,  for  we  were  blazing  the  trail  through  this  territory  when  it 
was  an  untrodden  wilderness,  and  it  is  ours  by  right  of  discovery; 
we  were  giving  laws  to  govern  the  conduct  of  the  stranger  in  this  field 
when  it  was  unknown  and  unconquered,  and  it  is  ours  by  right  of  con- 
quest; we  received  from  the  pioneers,  our  teachers,  some  of  whom  are 
with  us  now,  the  principles  and  precepts  on  which  has  been  built  up 
this  most  aggressive  department  of  surgery,  and  it  is  ours  by  right  of 
inheritance. 

Marion  Sims  was  not  a  general  surgeon  when  he  laid  down  the  la\A  s 
which  to-day  govern  the  surgery  of  the  gall-bladder,  when  he  fore- 
shadowed the  modern  treatment  of  gunshot  wounds  of  the  abdomen 


20  PRINCIPLES  AND  PRACTICE 

and  thereby  set  in  motion  a  tide  of  general  abdominal  surgery  of  which 
the  ebb  flow,  particularly  in  the  upper  zones  of  the  abdomen,  where 
we  have  joined  hands  with  the  general  surgeon,  is  already  overdue. 
Do  the  traditions  which  properly  belong  to  us  count  for  nothing? 
Shall  we  retire  into  the  background?  Shall  we  organize  a  society  of 
the  Cincinnati,  enter  into  our  second  childhood,  and  live  on  the  memories 
of  the  past?  Is  our  work  done?  Shall  we  say,  " Troy  has  been,  we  have 
been  Trojans?"  If  our  work  is  done,  why  should  we  not  go  at  once 
into  voluntary  liquidation?  Why  should  a  special  society  hold  another 
meeting?  But  so  long  as  in  the  diseases  of  women  there  are  practical 
and  scientific  problems  to  be  solved,  our  work  is  not  done.  Does  not 
the  increased  strain  of  modern  life,  notwithstanding  improved  knowl- 
edge of  sanitation  and  hygiene,  bring  about  exaggerations  of  pathology 
wdiich  will  demand  not  less  but  more  of  the  gynecologist?  If  we  do 
not  respect  our  own  specialty,  who  will?  Let  us  consider,  for  example, 
the  every-day  subject  of  dysmenorrhoea,  about  which  as  yet  we  know 
but  little;  the  causes  of  eclampsia,  of  which  we  know  less;  the  purpose 
of  menstruation,  of  which  we  know  nothing;  the  unknown  conditions, 
which  in  one  case  will  supply  defense  against  general  septic  peritonitis 
and  in  another  apparently  similar  case  will  open  the  way  to  a  rapidly 
fatal  peritoneal  infection.  Let  us  reflect  that  we  have  not  spoken  the 
last  word  on  the  surgical  treatment  of  descent,  retroversion,  and  other 
deviations  of  the  pelvic  organs;  let  us  consider  whether  in  the  next 
thirty  years  we  or  the  general  surgeons  are  going  to  make  such  im- 
provements in  practical  gynecology  that  the  hysteropexies,  the  hys- 
terorrhaphies,  the  suspensions,  the  fixations,  and  a  number  of  other 
procedures  may  look  to  our  successors  as  crude  and  irrational  as  the 
clamp  and  routine  use  of  the  drainage-tube  in  ovariotomy  look  to  us 
at  the  present  time. 

And  now,  supplementary  to  this  discussion,  may  I  oifer  a  sugges- 
tion? In  recent  years,  abdominal  surgery  has  so  far  engrossed  the 
mind  of  the  gynecologist,  not  to  mention  that  of  the  general  surgeon, 
that  by  comparison  the  minor  plastic  work  to  some  extent  has  been 
neglected  or  given  into  incompetent  hands.  It  is  perhaps  not  too 
much  to  say  that  out  fathers  in  their  day  did  better  plastic  surgery  than 
we  are  doing  in  ours.  Indeed,  a  revival  of  interest  may  be  necessary 
in  order  to  save  this  part  of  gynecology  from  becoming  a  lost  art. 
There  is  now  accumulating  a  very  appreciable  number  of  patients  on 
whom  plastic  operations,  some  of  them  repeated  on  the  same  patient 
many  times  over,  have  been  performed  with  indifferent  or  injurious 
results.  Many  such  patients  need  to  have  the  work  undone  or  done 
over  again.  And  this  class  of  cases  now,  therefore,  is  making  an  in- 
creasing demand  on  the  attention  of  the  competent  gynecologist.  It  is 
time,  therefore,  without  losing  sight  of  the  claims  of  capital  surgery, 
to  bestow  adequate  attention  on  the  homely  every-day  problems  of 
minor  g}-necology. 


PART  I 
aENERAL  PRINCIPLES 


CHAPTER   I 

thp:  physiological  periods  ix  the  life  of  wo^iax 

Develop:ment  from  infancy  to  maturity  and  decline  from  maturity 
to  senility  are  common  alike  to  man  and  to  woman.  In  man  the  ana- 
tomical and  physiological  changes  from  the  time  of  birth  to  the  period 
of  youth  and  virility  and  the  cessation  of  sexual  power  in  old  age 
are  gradual  and  even  processes,  relatively  free  from  special  outlay  of 
energy,  unmarked  by  specially  critical  periods,  and  unattended-  by 
pronoimced  nervous  or  mental  disturbance.  In  woman  these  transition- 
periods  are  characterized  by  greater  expenditure  of  energy,  by  more 
rapid  sexual  change,  and  by  more  distinct  nervous  and  psychic  phe- 
nomena; they  are  the  critical  turning-points  in  her  life.  At  the  first 
crisis — puberty — the  reproductive  organs,  more  complicated  than  those 
of  the  male  and  hitherto  unproductive,  suddenly  become  the  centre 
of  great  and  rapid  development;  from  this  period  forw'ard  until  the 
second  and  final  crisis — the  menopause — her  vital  forces  are  especially 
subject  to  the  exactions  of  menstruation  and  maternity.  After  the 
menopause  comes  the  end  of  active  sexual  life  and  the  inversion  of 
the  developmental  processes  of  infancy  and  puberty;  so  that  in 
embryonic  life  and  early  infancy  the  physiological  lines  that  mark 
the  distinction  of  sex  nearly  coincide,  and  anatomical  differences  have 
little  more  than  potential  significance;  as  childhood  recedes  these 
lines  diverge;  as  maturity  progresses  they  separate  more  and  more; 
finally,  in  old  age  they  draw  together  until  in  the  second  childhood,  as 
in  the  first,  they  again  nearly  coincide. 

The  life  of  woman  may  be  di\-ided  into  five  periods,  each  correspond- 
ing to  a  special  phase  of  her  sexual  existence;  they  are  infancy,  puberty, 
maturity,  the  menopause,  and  senility. 


INFANCY 

Infancy  includes  the  first  ten  or  twelve  years  of  life,  and,  although 
a   period   of   great    pathological    significance,  is   rather   a   subject   of 

(21) 


22  GENERAL  PRINCIPLES 

paediatrics  than  of  gynecology.  During  this  period  the  reproductive 
organs  are,  for  the  most  part,  functionally  dormant;  they  are  under- 
going a  gradual  development  preparatory  to  the  more  rapid  and 
radical  changes  of  puberty.  Infections  and  inflammations  occasionally 
arise;  neoplasms  and  traumatisms  are  rare;  congenital  malformations,  if 
present,  usually  are  overlooked  until  the  period  of  puberty  or  maturity, 
when,  by  reason  of  some  defect  in  the  function  of  menstruation,  coitus, 
or  parturition,  they  become  evident;  displacements  of  the  infantile 
uterus,  although  possible,  have  little  or  no  clinical  significance. 


PUBERTY 

Puberty  is  the  critical  transition-period  in  which  the  child  becomes 
the  woman.  The  relations  and  influences  of  this  period  are  funda- 
mental, not  only  in  the  reproductive  organs  but  in  the  entire  woman,  so 
that  upon  the  normal  course  of  it  depends  much  of  the  after  health, 
comfort,  and  usefulness  of  the  individual. 

The  Anatomical  Basis  of  puberty  is  the  full  physical  development 
of  the  woman.  The  infantile  uterus  is  small,  soft,  and  plastic;  it  varies 
in  size  from  that  of  early  infancy  (Figure  1)  to  that  of  the  child  uterus 
just  before  puberty;  at  the  beginning  of  puberty  the  uterine  canal 
would  measure,  perhaps,  two  inches;  when  fully  developed  at  the  end 
of  puberty  it  should  measure  two  and  one-half  inches. 

Figure  1 


Uterus,  Fallopian  tubes,  and  ovaries  of  an  infant  one  month  old.     Natural  size. 


The  cervix  of  the  infantile  uterus  is  two-thirds,  and  the  corpus  one- 
third,  as  long  as  the  entire  organ.  These  proportions  when  the  organ 
is  fully  developed  at  the  end  of  puberty  are  reversed— that  is,  the  corpus 
represents  two-thirds  and  the  cervix  only  one-third  of  the  length  of 
the  mature  uterus.  At  maturity  the  longitudinal  axis  extending  from 
the  OS  externum  to  the  fundus  measures  three  inches;  the  transverse 


THE  PHYSIOLOGICAL  PERIODS  IN   THE  LIFE  OF  WOMAN    23 

axis  of  the  corpus  uteri  measured  laterally  from  horn  to  horn  is  two 
inches,  and  measured  l)\'  the  lon<;est  anteroposterior  diameter  is  one 
incli.  The  fundus  of  the  infantile  uterus  is  flat;  the  fundus  of  the  mature 
uterus  is  convex  and  dome-shaped.  The  mucosa  of  the  infantile  uterus 
presents  an  arbor  vifcc  arranf^ement  throughout  the  corpus  and  cervix; 
at  maturity  this  arrangement  is  confined  to  the  cervix. 

Developmental  changes  similar  in  extent  to  those  above  outlined 
occur  in  the  ovaries  and  in  the  other  genital  organs.  Puberty  is  marked 
also  by  enlargement  of  the  pelvis  and  breasts,  by  the  appearance  of 
hair  on  the  mons  veneris,  vulva,  and  armpits,  and  by  general  rounding 
out  of  the  form  with  adipose  tissue. 

The  Physiological  Features  of  puberty  are  the  onset  of  inemtrua- 
iion  and  ovulation  and  notable  psychic  changes,  all  of  which  indicate 
that  the  reproductive  organs  and  the  sexual  nervous  organization  are 
approaching  maturity  and  that  the  girl  is  preparing  for  maternity. 

Menstruation 

Menstruation  is  characterized  by  a  bloody  mucous  discharge  from 
the  uterus;  this  discharge  contains  epithelial  cells  from  the  uterus  and 
vagina;  it  begins  with  puberty,  and,  unless  interrupted  by  uterogesta- 
tion  and  lactation  or  by  disease,  normally  recurs  in  regular  periods 
until  the  time  of  the  menopause.  The  phenomena  of  menstruation 
are  both  general  and  local. 

I.  The  General  Phenomena  of  Menstruation  are  as  follows: 

1.  Slight  elevation  of  pulse-rate  and  temperature  at  the  onset. 

2.  Tendency  to  slight  physical  depression  and  inactivity. 

3.  Sensations  of  heat  and  cold. 

4.  Swelling  of  the  breasts  and  thyroid  gland. 

5.  Discomfort  and  throbbing  in  the  head,  weight   in   the  pelvis 

and  back,  and  irritability  of  the  bladder. 
These  disturbances  are  subject  to  wide  variations.  In  some  cases 
they  are  absent;  in  others  they  are  so  slight  as  almost  to  escape  notice, 
or  so  severe  as  to  render  life  miserable  and  useless.  Painful  men- 
struation— that  is,  dysmenorrhoea — is  always  proof  of  some  patho- 
logical condition.    See  chapter  on  Dysmenorrhoea. 

II.  The  Local  Phenomena  of  Menstruation  are  recognized  in  three 
stages : 

1.  Stage  of  invasion — discharge  of  mucus. 

2.  Stage  of  persistence — flow^  of  blood. 

3.  Stage  of  decline — discharge  of  mucus. 

Discharge  of  mucus  before  and  after  the  flow  of  blood  is  an  essential 
part  of  the  menstrual  flux;  in  lower  animals  the  menstrual  discharge, 
if  present  at  all,  is  entirely  of  mucus.  In  the  human  race  the  lower 
the  intellectual  scale  the  greater  the  relative  quantity  of  mucus;  the 
higher  the  scale  the  greater  the  relative  quantity  of  blood. 

Amenorrhcea. — Amenorrhoea  is  the  absence  of  menstruation;  it  may 
be  physiological  or  pathological. 


24  GENERAL  PRINCIPLES 

Physiological  Amenorrhoea.— Physiological  absence  of  menstruation 
occurs : 

1.  Prior  to  puberty. 

2.  At  irregular  intermenstrual  periods  during  the  establishment 

of  pubert}'. 

3.  During  pregnancy  and  lactation. 

4.  At  irregular  intermenstrual  periods  during  the  climacteric. 

5.  After  the  menopause. 

Pathological  Amenorrhoea. — A  discussion  of  the  pathological  causes  of 
amenorrhoea  may  be  found  in  the  chapter  on  Amenorrhoea. 

Age  of  First  Menstruation. — The  age  at  which  menstruation  first 
appears  varies  widely  with  individuals.  Climate  and  heredity,  espe- 
cially the  former,  are  determining  factors.  In  the  United  States  it 
first  appears  on  the  average  about  the  fourteenth  or  fifteenth  year, 
sometimes  as  early  as  the  ninth  or  tenth,  or  as  late  as  the  eighteenth. 
In  the  Arctics  the  average  age  is  sixteen  years  and  in  the  tropics  ten 
or  eleven. 

Precocious,  Protracted,  and  Scanty  Menstruation  will  be  presented 
in  chapters  on  these  subjects. 

Frequency  of  Menstruation. — The  human  menstrual  cycle  covers 
a  period  of  about  twenty-eight  days.  Variations  of  a  few  days  are 
common  and  usually  harmless. 

Quantity  of  Menstrual  Discharge  and  Duration  of  Flow. — ^The 
average  amount  of  menstrual  fluid  lost  in  a  single  period  is  from  six 
to  eight  ounces.  The  minimum  normal  flow  is  two  and  the  maximum 
ten  ounces.  A  plethoric,  well-nourished  woman  may  menstruate 
freely  for  eight  to  ten  days  without  ill  effect,  and  may  lose  an  amount 
of  blood  which  would  undermine  seriously  the  strength  of  an  anaemic, 
poorly  nourished  woman.  What  would  be  normal  for  one  woman, 
therefore,  would  be  abnormal  for  another.  The  usual  means  of  esti- 
mating the  quantity  of  blood  lost  is  by  counting  the  napkins  used. 
The  average  number  is  fourteen.  Nothing  approaching  exactness 
is  gained  by  this  method,  since  napkins  vary  in  size  and  capacity  for 
absorption,  and  since  one  woman  will  tolerate  an  oversaturated  napkin 
while  another  will  scarcely  permit  the  soiling. 

Anatomy  of  Menstruation. — Although  menstruation  has  been  the 
subject  of  many  strange  superstitions  and  speculations,  yet  nothing 
is  known  of  the  utility,  cause,  or  significance  of  it.  Numerous  con- 
flicting opinions  concerning  the  anatomy  of  menstruation  have  been 
put  forth:  one,  that  the  corporeal  mucosa  is  stripped  off  clear  to  the 
muscular  layer  at  each  recurring  flow;  another,  that  only  the  epithe- 
lial layer  is  shed;  another,  that  a  newly  organized  tissue  is  developed 
during  the  intermenstrual  period,  and  that  this  alone  is  cast  off.  The 
notion  that  the  surface  epithelium  is  thrown  off  in  the  process  of 
n^ienstruation  has  arisen  from  faulty  methods  of  investigation.  Ob- 
servations made  on  the  uteri  of  women  who  had  died  from  freezing 
or  from  infectious  disease  during  menstruation,  or  upon  uteri  removed 
twenty-four  hours   or   longer   after  death;   or  upon  freshly   removed 


PLATE    II 


FIGURE   1 


Mli 


'K 


^"f 


FIGURE    2 


FIGURE   8 


•f./ 


Anatomy  of  Menstruation  (Modified  from  Gebhard). 

Figure  1. — Stance  of  pre-nienstrual  congestion. 
Figure  2. — Stage  of  sub-epithelial  hsetnatoma. 
Figure  3. — Stage  of  bursting  of  blood  through  the  surface  epithelium      90  diameters. 


77/ A'  I'llYSIOlJHilCAL   PERIODS   IX    THE   LIFE   OF    WOMAX      25 

specinioiis  in  which  the  surface  epithelium  had  been  injured  in  the 
han(lhn<j,  have  supported  the  conclusion  tiiat  the  surface  epithehuni 
is  siied  duriufi;  menstruation,  when  in  reahty  the  loss  of  epithelium 
was  post  mortem,  (iehhard,  of  Berlin,  has  put  forth  a  rational  inter- 
pretation of  the  anatomical  chan<i:es  of  menstruation.  Ilis  ohserxations 
upon  fresh  human  material  carefully  prepared  indicate  that  in  men- 
struation there  is  no  shedding  of  the  surface  einthcliuin. 
Three  sta<i;es  of  menstruation  are  recognized: 

1.  Premenstrual  C()nf>;estion.     Plate  II.,  Figure  1. 

2.  Sul)ei)ithelial  hu-matoma.     Plate  II.,  Figure  2. 

'A.  Bursting  of  blood  through  surface  epithelium  and  post-menstrual 
al)sorption.     Plate  II.,  Figure  3. 

The  connective  tissue  of  the  endometrium  is  of  the  embryonal  type 
and  is  permeated  with  delicate  blood-vessels.  These  vessels  participate 
in  the  general  pelvic  congestion  that  precedes  menstruation,  and 
readily  give  forth  an  efi'usion  of  blood  into  the  embryonal  connective 
tissue;  the  effused  blood  takes  the  direction  of  least  resistance — that 
is,  to  the  surface  of  the  endometrium.  Under  the  surface  epithelium 
the  blood  collects  in  small  quantities,  forming  what  may  be  termed 
subepithelial  ha^matomata.  With  increasing  pressure  the  blood  passes 
between  the  epithelial  cells  of  the  surface,  elevating  groups  of  cells 
from  the  basement  membrane  and  occasionally  breaking  off  small 
fragments  of  epithelium.  With  lessening  blood-pressure  the  hemor- 
.  rhage  becomes  less  abundant,  and  finally  the  blood  ceases  to  pass 
through  the  epithelial  barrier;  then  follows  absorption  of  the  effused 
blood  from  the  connective  tissue  and  subepithelial  spaces.  The  epithe- 
lium that  had  been  lifted  from  the  basement  membrane  sinks  back 
into  its  former  relations.  Any  minute  areas  accidentally  denuded 
are  quickly  covered  by  new  epithelium  regenerated  from  adjoining 
surface  epithelium  and  gland  epithelium.  The  anatomical  events  of 
menstruation  as  set  forth  by  Gebhard  may  possibly  have  to  be  modified 
in  accord  with  the  conclusions  of  the  followers  of  Heap,  who  made  his 
observations  post  mortem  on  the  uteri  of  monkeys.  His  results  indi- 
cated, but  did  not  clearly  prove,  that  in  menstruation  the  whole 
corporeal  mucosa  is  cast  off. 

Ovulation 

Ovulation  involves  the  maturing  and  rupture  of  the  Graafian  folKcle 
and  the  escape  of  the  ovum.  Formerly,  menstruation  was  commonly 
thought  to  be  an  external  manifestation  of  ovulation  and  dependent 
upon  it;  but  whatever  may  be  the  relation  between  these  two  func- 
tions, that  of  cause  and  effect,  for  the  following  reasons,  is  no  longer 
tenable : 

1.  There  is  a  cyclical  periodicity  in  menstruation,  and  there  is  no 
such  periodicity  in  the  maturing  of  the  Graafian  follicle  and  discharge 
of  the  ovum;  the  process  of  ovulation  is  continuous,  and  occurs  even 
in  the  mature  foetus. 


26  GENERAL   PRINCIPLES 

2.  Menstruation  sometimes  continues  after  removal  of  the  ovaries. 

3.  On  opening  the  abdominal  cavity  during  menstruation  one  fre- 
quently fails  to  find  a  fresh  corpus  luteum  in  either  ovary;  on  the 
contrary,  he  frequently  finds  it  during  the  intermenstrual  period. 

Figure  2 


Section  of  ovary  (magnified).  1.  Outer  covering.  2.  Graafian  follicles  in  earliest  stage  of_ develop- 
ment. 3.  Graafian  follicles  in  more  advanced  stage  of  development;  the  largest  follicle  is  almost 
mature.  3'.  Follicle  from  which  ovum  has  escaped.  4.  Slightly  developed  follicles.  5.  Peripheral 
stroma.  6.  Central  stroma.  7.  Corpus  luteum.  Modified  from  Schron's  drawing  of  the  ovarj^  of  a 
cat. 

Figure  3 


Mature  ovary,  Fallopian  tube,  and  uterus,  from  a  woman  twenty-five  years  of  age.    Natural  size. 


THE  ['UYSIDIJXIICAL   PERIODS   I.\    THE   LIFE  OF    \\f)MA\     27 

4.  ()\iilatii)ii  occurs  in  the  absence  of  menstruation;  this  is  prpyed 
by  tiie  fact  that  conception  may  take  phice  chiriiif;  the  j)eri(jrl  of  lacta- 
tion, and  even  after  the  menopause. 

Although  the  dependence  of  menstruation  on  ovulation  has  not 
been  established,  there  is  yet  reason  to  conclude  that  ovulation  and 
menstruation  are  both  under  the  control  of  the  same  ner\e  appa- 
ratus, and  that  the  nerves  of  the  uterus  and  ovaries  have  a  certain 
coordination. 

The  Goitre  of  Puberty. — Tiie  changes  of  puberty  are  in  some  cases 
associated  with  an  enlargement  of  the  thyroid  gland,  called  goitre, 
a  condition  that  often  disappears  with  the  complete  establishment 
of  menstruation.  In  early  goitre  the  glands  are  soft  and  almost  fluc- 
tuating. If  the  enlargement  persists,  the  tumor  becomes  fibrous, 
hard,  and  intractable.  Such  enlargement  may  be  treated  in  the  early 
stage  with  inunctions  of  biniodide  of  mercury,  .30  grains  to  the  ounce. 
This  should  be  applied  daily  for  periods  of  four  or  five  days.  When  the 
skin  becomes  irritated  the  application  should  be  interrupted  until  the 
irritation  has  subsided,  and  then  resumed.  These  inunctions,  together 
with  the  continued  used  of  calomel  or  the  bichloride  of  mercury,  in 
minute  doses,  will  result  sometimes  in  rather  prompt  disappearance  of 
the  swelling.  The  thyroid  extract  in  doses  of  2  grains,  three  times  a 
day,  will  in  some  cases  effect  a  rapid  cure;  if  distinct  improvement  is 
not  apparent  in  two  or  three  weeks  the  drug  should  be  discontinued; 
in  any  case  the  use  of  it  should  be  guarded,  and  the  dose  regulated  if 
necessary  to  an  amount  that  will  not  cause  disagreeable  ner\'ous 
symptoms. 

Care  during  Puberty. — Although  the  appearance  of  menstruation 
indicates  that  maternity  is  possible,  it  by  no  means  follows  that  the 
development  of  the  individual  is  complete  at  this  time,  nor  that  she 
is  capable  of  fulfilling  the  requirements  of  maternity.  Before  the 
twentieth  year  the  nervous  system  is  imequal  to  the  strain  of  child- 
bearing  and  child-rearing;  the  muscles  are  inadequate  to  the  carrying 
and  expulsion  of  the  child;  and  the  pehis  is  often  too  small  to  give  it 
safe  exit.  The  period  of  puberty  should  be  taken  as  extending  not 
only  over  the  few  months  required  for  the  establishment  of  menstrua- 
tion, but  as  including  the  time  necessary  for  full  physical  develop- 
ment. During  this  period  the  energy  of  the  girl  is  taxed  by  the  rapidity 
of  sexual  development,  by  the  great  liability  to  circulatory  disturb- 
ances, by  the  physical  and  mental  strain  of  education,  and  by  the 
conventionalities  of  society.  The  necessity,  therefore,  for  great  care 
is  apparent.  Nutritious  and  simple  diet,  frequent  rest,  moderate 
amusements,  and  adequate  exercise  are  essential.  Study,  especially 
during  menstruation,  should  never  be  pressed  to  the  point  of  fatigue. 
Inasmuch  as  passional  life  now  begins,  and  the  whole  nervous  organiza- 
tion is  therefore  subject  to  new  impulses  and  requirements,  books 
and  associates  should  be  selected  carefully,  and  whatever  may  unduly 
excite  the  emotions  should  be  excluded.  Errors  committed  now  may 
have  grave  consequences,  such  as  malnutrition,  psychoses,   sterility, 


28  GENERAL  PRINCIPLES 

menstruial  and  other  functional  disorders,  and  may  make  the  woman  a 
hopeless  invalid.  For  reasons  already  given,  one  of  the  most  serious 
errors  is  premature  marriage. 

Figure    4 


Ovary  and  Fallopian  tube,  from  a  woman  forty-one  years  of  age.     Natural  size.     Atrophic  processes 
and  consequent  decrease  in  size  of  the  ovary  and  tube  already  begun. 

Education. — According  to  prevailing  ideas,  the  higher  education 
and  civilization  strongly  tend  to  check  and  pervert  the  development 
of  woman,  to  cause  numerous  weaknesses,  to  increase  the  burdens  and 
dangers  of  maternity,  and  to  lessen  the  vigor  of  the  offspring.  We 
are  told  that  the  republic  is  in  danger  from  deterioration  of  the  edu- 
cated classes.  These  pessimistic  forebodings  have  arisen  and  gained 
headway  rather  upon  assertion  than  upon  known  fact.  The  ability  of 
the  squaw  immediately  after  parturition  to  resume  the  march  is  urged 
often  as  an  argument  against  the  higher  education  of  woman;  on  the 
other  hand,  observation  among  Indian  women  has  shown  abundantly 
that  want  of  care  during  and  after  labor  is  the  constant  cause  of 
complete  prolapse  of  the  uterus,  vagina,  and  bladder,  and  of  numerous 
other  diseases  which  are  relatively  much  more  prevalent  among  them 
than  among  the  higher  classes  of  civilized  women.  The  educated  woman 
could  "resume  the  march"  if  it  were  necessary;  history  has  shown 
many  heroic  examples;  but  education  has  taught  her  that  this  is  unsafe. 
The  savage  woman  looks  old  and  withered  at  thirty ;  the  civilized  woman 
preserves  something  of  youth  until  after  the  age  of  fifty.  The  highest 
civilization  if  carried  forward  under  proper  conditions  should  more 
than  offset  any  deteriorating  influence  which  may  come  of  a  departure 
from  primitive  conditions;  it  should  give  to  the  civilized  race  a  vitality 
much  greater  than  that  of  the  savage,  and  to  the  civilized  woman  a 
power  of  resistance  which,  if  properly  trained  and  directed,  will  enable 
her  to  endure  and  to  survive  many  trials  to  which  a  savage  woman 
would  succumb.  To  make  the  deterioration  of  woman,  and  through 
this  the  enfeeblement  of  the  race,  a  price  which  must  be  paid  for  the 


THE  I'HYSIOLOO'ICAL    I'EinoDS   IX    THE   LIFE  OF   WOMAN     29 

liijjluT  education  and  (■i\ilizati()ii.  would  be,  seemingly  to  reverse  the 
law  of  e\olutit)n  and  to  put  in  its  place  a  law  of  the  survival  of  the 
unfittest. 

MATURITY 

The  time  of  sexual  maturity  extends  from  the  end  of  puberty  to 
about  the  forty-second  year,  and  under  normal  conditions  is  a  rela- 
tively healthy  period.  Unlike  puberty  and  the  menopause,  it  is  com- 
paratively free  from  neuroses  and  psychoses,  except  those  connected 
with  pregnancy.  The  woman  is  subject,  however,  to  the  burdens  and 
accidents  of  menstruation,  ovulation,  pregnancy,  maternity,  physical 
and  mental  overstrain,  and  to  the  dangers  of  puerperal  and  other 
infection,  among  which  especially  may  be  mentioned  gonorrhoea — a 
potent  cause  of  vulvovaginitis,  metritis,  salpingitis,  ovaritis,  peri- 
tonitis, cystitis,  pyelitis,  and  nephritis. 

During  this  period  the  non-malignant  neoplasms  more  frequently, 
and  the  malignant  neoplasms  less  frequently,  endanger  life  and  health. 

Figure  -5   ■ 


Natural  size  of  ovan.-,  Fallopian  tube,  and  uterus  of  a  woman  seventy  years  of  age.  Senile  atrophy 
of  the  reproductive  organs  complete.  Rudimentarj^  ovarj-  and  tube.  Uterus  atrophied  to  ab^ut  two- 
thirds  of  the  mature  size. 


THE   MENOPAUSE 

The  menopause,  sometimes  called  the  climacteric,  sometimes  the 
change  of  life,  is  the  second  critical  period.  It  usually  takes  place 
between  the  ages  of  forty  and  fifty;  the  occurrence  of  this  crisis  before 
the  fortieth  or  after  the  fifty-second  year  is  abnormal;  it  continues 
from  three  to  five  vears.     Pathological  causes  more  or  less  recogniz- 


30  GENERAL  PRINCIPLES 

able,  and  the  influence  of  heredity,  may  shorten  or  lengthen  it.  In 
very  cold  climates  both  puberty  and  the  menopause  are  delayed.  The 
opposite  is  true  in  warm  climates. 

The  Anatomical  and  Physiological  Basis  of  the  Menopause  is  atrophy 
and  cessation  of  function.  This  critical  period  is  characterized  by 
the  following  senile  changes  in  all  the  reproductive  organs,  some  of 
which  are  pathological. 

1.  Senile  changes  in  the  ovary: 

a.  Atrophy,  induration,  and  shrinkage  to  rudimentary  size. 
h.  Disappearance  of  Graafian  follicles. 
c.  Cessation  of  function. 

2.  Senile  changes  in  the  Fallojnan  tubes: 

a.  Shortening  and  narrowing;  often  complete  obliteration  of 

lumen. 
h.  Destruction  of  epithelial  elements. 

3.  Senile  changes  in  the  uterus: 

a.  Atrophy  of  entire  organ  to  rudimentary  size;  may  be 
reduced  to  a  hard,  wedge-shaped  body,  one-fourth  size 
of  mature  organ. 

h.  Muscular  and  glandular  elements  become  rudimentary. 

c.  Canal  may  close  at  internal  os,  or  external  os,  or  become 

obliterated  throughout. 

d.  Secretions  may  be  locked  up  by  obliteration  of  the  cervical 

canal  producing  pyometra  or  hydrometra. 

e.  Vaginal  portion  may  disappear,  making  the  upper  part  of 

the  vagina  continuous  with  the  uterine  canal. 

4.  Senile  changes  in  the  vagina: 

a.  Shortening,  narrowing,  and  loss  of  elasticity. 

b.  Loss  of  pavement  epithelium  and  substitution  of  a  hard 

surface  containing  more  or  less  cicatricial  tissue. 

c.  Contraction  of  introitus  vaginae. 

5.  Senile  changes  in  the  vulva: 

a.  Same  as  in  vagina — great  contraction  and  loss  of  elasticity. 

b.  Destruction    or   impairment    of   vulvovaginal   glands   and 

vulvar  follicles. 

c.  Cutaneous  surface  dry  and  scaly. 

d.  Hair  on  mons  veneris  may  turn  gray. 

6.  Senile  changes  in  the  mammae: 

a.  Loss  of  glandular  elements  and  cessation  of  function. 

b.  Atrophy   and   shrinkage;   sometimes   the   atrophic   loss  is 

made  up  or  more  than  made  up  by  the  deposition  of  fat. 

The  Essential  Phenomenon  of  the  Menopause  is  permanent  arrest 
of  all  functions  peculiar  to  the  reproductive  organs.  It  is  the  inversion 
of  the  developmental  process  of  puberty.  It  marks  the  end  of  active 
sexual  life.    The  atrophic  changes  are  known  as  senile  atrophy. 

The  Symptoms  of  the  Normal  Menopause  are  referable  to  two 
stages:  a  stage  of  menstrual  irregularity  preceding  the  cessation  of  the 
menses,  and  a  post-cessation  stage  of  variable  systemic  disturbances. 


THE  PHYSIOLOGICAL   PERIODS   IS   THE  LIFE  OF  ll'O.l/.l.V     31 

In  normal  or  nearly  normal  cases  the  menstrnal  irref^nlarities  and  the 
systemic  disturbances  are  slight.  The  woman  may  at  times  he  uimsually 
capricious  and  emotional;  yet  she  passes  throujijh  this  physioioj^ical 
crisis  with  only  a  few  minor  perturbations,  such  as  the  characteristic 
vasomotor  Hushes,  perspiration,  xcrtij^o,  somnolence,  num})ness,  and 
t'aintness.  The  menstrual  function  ceases  as  it  l)egan,  with  marked 
symptoms  referable  to  tlu>  nerxons  system. 

Symptoms  of  Abnormal  Menopause. — Irritability,  apprehensiveness, 
hysteria,  melancholia,  and  other  psychic  disturbances,  more  or  less 
exaggerated,  are  common  in  the  abnormal  cases.  The  How  may  become 
continuous;  it  may  become  so  excessive  as  almost  to  amount  to  dan- 
gerous hemorrhage;  or  life  be  jeopardized  by  a  slow,  continuous  drain. 
There  is  an  increased  tendency  to  malignant  disease  of  the  uterus  and 
breasts  during  this  period,  the  excessive  fear  of  which  may  almost 
amount  to  a  symptom  of  melancholia. 

The  menopause  often  cures  pelvic  disease;  this  is  because  pathology 
is  physiology  modified  by  disease,  and  because  atrophic  changes  when 
they  arrest  physiological  processes  may  also  at  the  same  time  put 
an  end  to  pathological  processes.  Especially  is  this  true  if  the  patho- 
logical processes  have  depended  upon  the  functional  activity  of  the 
organs  involved.  It  therefore  follows  that  a  woman  who  has  suffered 
for  years  from  chronic  uterine  or  ovarian  disease  may  now  enter  upon 
a  long  period  of  increased  vigor  and  robust  health.  It  may,  however, 
be  a  dangerous,  even  a  fatal  mistake  to  assume  that  the  ills  occurring 
at  this  time  of  life  properly  belong  to  the  menopause;  that  they  need 
give  no  anxiety;  that  they  will  disappear  with  it;  and  that  they  there- 
fore require  no  attention.  Although  such  a  notion  prevails,  yet  some 
of  the  most  grave  disorders  of  the  menopause  are  consequent  upon 
pathological  states  for  w^hich  atrophy  of  the  reproductive  organs  gives 
no  relief.  Continuous  and  profuse  hemorrhages  and  excessive  nervous 
disturbances  are  matters  of  specially  grave  solicitude,  and  since  the  one 
may  indicate  malignant  disease  and  the  other  may  tend  to  mental 
derangement,  prompt  diagnosis  and  energetic  treatment  may  be 
imperative. 

SENILITY 

The  period  of  senility  follows  the  menopause  and  continues  to  the 
end  of  life;  it  is  the  decline  of  life,  and  is  normally  a  period  of  repose. 
The  functions  of  the  reproductive  organs  having  ceased,  the  organs 
have  little  physiological  significance.  The  special  disorders  and  dangers 
of  this  period,  such  as  malignant  growths,  senile  vulvovaginitis,  and 
senile  endometritis,  will  be  considered  in  the  proper  connections. 


CHAPTER  II 
SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE 

Septic  infection  formerly  caused  an  appalling  mortality  in  the  major 
gynecological  operations  and  made  the  minor  manipulations  extra 
perilous.  The  fear  of  infection  was  so  great  that  when  the  malady 
was  neither  fatal  nor  very  disabling  the  practitioner  often  used  tem- 
porizing measures  however  unpromising,  to  the  exclusion  of  surgical 
measures  however  rational.  Now  the  application  of  the  aseptic  principle 
has  made  all  gynecological  procedures  relatively  safe.  Micro-organisms 
are  clearly  the  cause  of  the  septic,  that  is,  the  so-called  inflammatory 
diseases  of  women.  At  birth  the  entire  genital  tract  is  sterile  but  in  a 
short  time  the  vagina  normally  becomes  the  abode  of  numerous  non- 
pathological  organisms  which  have  gained  entrance  from  the  exterior 
through  the  vulva.  The  cervix,  the  corpus  uteri,  and  the  Fallopian 
tubes  are  normally  sterile. 

Nature  offers  a  double  barrier  against  the  lodgement  and  growth  of 
'pathological  organisms  in  the  vagina,  first  through  the  action  of  the 
blood-stream  in  walling  off  and  destroying  them,  as  in  other  parts  of 
the  body,  and  second  through  the  acid  medium  of  the  normal  vaginal 
secretions  in  which  they  grow  poorly.  However,  this  double  barrier 
is  far  from  being  absolute.  Either  by  numbers  or  virulence  bacteria 
may  easily  overcome  the  segregating  and  destroying  action  of  the 
blood  elements,  and  this  action  may  itself  be  impaired  by  the  lowered 
general  condition  of  the  individual.  The  normal  acidity  of  the  vagina 
is  so  far  neutralized  by  the  alkalinity  of  the  blood  at  the  time  of  the 
menstrual  flow,  and  in  other  bleeding  conditions  of  the  genital  tract, 
that  its  protective  action  may  be  lowered  or  destroyed  when  the 
vagina  is  exposed  to  infection  by  the  hand  or  instrument  of  the  ex- 
amining physician.  It  is,  therefore,  imperative  that  every  aseptic 
precaution  be  employed,  not  only  in  surgical  procedures  but  in  the 
examination  of  the  patient  as  well. 

Sepsis  is  the  general  term  for  all  surgical  infections  of  microbic 
origin.  The  term  asepsis,  and  the  corresponding  adjective  aseptic, 
are  used  to  imply  the  absence  of  these  infections.  The  phenomena 
of  sepsis  are  due  doubtless  to  the  products  of  bacteria  more  than  to 
the  bacteria  themselves. 

SEPTIC    INFECTION 
Forms  of  Infection 

Septicaemia. — The  presence  of  infectious  microbes  in  the  circula- 
tion, together  with  the  chemical  action  of  their  products,  gives  rise  to 
the  condition  called  septicaemia. 

(32) 


PLATE    III 


..  \ 


v& 


'*ig;- 


Bacillus  Coli  Communis. 


I    <^="    ^M.    4«    »      * 


Gonococcus. 


>::)., 


fe  ••/<? 


/    -1' 


streptococcus  Pyogenes. 


Bacillus  Tuberculosis. 


U%-=:#  =^^- 


Pneumococcus. 


Staphylococcus. 


Magnified   lOOO  diameters. 


SEPTIC  INFECTION  AND  ASEPTIC   TECHNIQUE  33 

Toxaemia. — Certain  microbes  exist  locally  and  may  si-nd  ont  their 
pnxlucts  thronuh  the  circnlation,  thereby  prodncin^-  srptic  toxa'niia. 

Saprsemia.  When  the  toxjemia  is  due  to  the  products  of  putre- 
facti\c  bacteria,  it  often  is  called  sapnemia. 

Pyaemia. — When  pus  emboli  are  carried  tlirouti;h  the  circulation 
from  a  focus  of  suppuration  to  set  up  other  foci  in  ditt'erent  portions 
of  the  body,  the  conditions  is  called  j)\iemia. 

The  above  terms  and  others  like  them,  although  widely  used,  are 
not  absolutely  definite.  An  appreciation  of  their  meaning,  however, 
is  essential  to  a  knowledge  of  modern  surgical  literature. 

Microbic  invasion  may  be  in  the  form  of  wound  infection  or  may 
occur  in  the  unbroken  cutaneous  and  mucous  structures. 

Forms  of  Bacteria. 

The  micro-organisms  most  common  in  gynecology  are: 

Gonococcus  of  Xeisser,  Bacillus  coli  communis, 

Staphylococcus  pyogenes  aureus,        Streptococcus  pyogenes, 
Staphylococcus  pyogenes  albus,  Bacillus  tuberculosis. 

Among  the  microbes  less  common  in  gynecology  are: 
Bacillus  pyocyaneus,  Pneumococcus, 

Bacillus  typhosus,  Streptothrix  actinomyces, 

Bacillus  diphtherise.  Bacillus  aerogenes  capsulatus. 

Gonococcus. — The  gonococcus  is  the  microbe  of  gonorrhoea  and  is 
invariably  present  in  the  urethral  discharge  in  gonorrhoea,  and  also  in 
other  parts  of  the  genital  tract  when  they  are  the  seat  of  gonorrhoeal 
infection.  A  most  striking  peculiarity  of  the  germ  is  the  power  to 
penetrate  and  intrench  itself  in  the  deeper  layers  beneath  the  mucous 
surfaces,  especially  in  glandular  structures.  It  may  also  migrate  to 
distant  organs,  ha\'ing  been  found  in  the  joints  in  cases  of  gonorrhoeal 
arthritis,  in  the  perspiration,  and  in  the  structures  of  the  heart.  The 
greatest  pathogenic  significance  of  the  germ  is  due  to  the  destructive 
action  which  it  exerts  upon  infected  organs.  It  may  set  up  general 
septicfemia,  but  more  commonly  remains  localized.  It  is  very  persistent 
and  destructive,  especially  in  the  infantile  vagina,  in  the  Fallopian 
tubes  of  adults,  in  the  conjunctiva,  and  in  the  joints. 

Staphylococcus  Pyogenes  Aureus  and  Albus. — Staphylococcus  pyo- 
genes aureus  and  albus,  which  resemble  one  another  in  form,  are 
the  most  widely  distributed  and  most  common  causes  of  suppuration. 
The  former  is  found  in  almost  all  localized  abscesses  and  in  various 
other  pyogenic  conditions.  It  varies  in  pathogenic  power  from  com- 
parative mildness  to  great  virulence.  The  latter  is  less  virulent.  Both 
varieties  often  are  associated  with  other  pyogenic  microbes. 

Streptococcus  Pyogenes. — Streptococcus  pyogenes  is  one  of  the 
most  virulent,  fatal,  and  important  of  the  pyogenic  microbes,  and 
is  especially  dangerous  as  a  cause  of  puerperal  and  traumatic  septi- 
caemia and  septic  peritonitis.  It  is  the  micro-organism  of  erysipelas. 
3 


34  GEXERAL   PRIXCIFLES 

Unlike  the  gonococciis,  which  spreads  preferably  by  way  of  the  mucosa, 
this  germ  follows  the  lymph-vessels  and  blood-vessels. 

Bacillus  CoU  Coimnuiiis. — Bacillus  coli  communis  is  a  normal  in- 
habitant of  the  intestine,  and  is  a  frequent  cause  of  peritonitis  fol- 
lowing intestinal  lesions  and  of  puerperal  infection  and  of  cystitis. 

Bacillus  Tuberculosis. — Bacihus  tuberculosis  has  been  found  in 
all  of  the  genito-urinary  organs  and  very  frequently  in  tuberculous 
peritonitis  and  salpingitis.  It  is  seldom  a  cause  of  traumatic  infection, 
and  is  therefore  not  to  be  feared  as  a  factor  in  surgery.  On  the  con- 
trary, surgical  operations  are  said  to  have  a  decided  inhibitory  effect 
on  the  progress  of  tuberculous  peritonitis,  the  disease  having  in  some 
cases  disappeared  after  simple  exploratory  incision.  It  is,  however, 
doubtful  whether  such  a  result  should  be  regarded  as  post  hoc  or 
propter  hoc. 

ASEPTIC    TECHNIQUE 

The  causation  and  course  of  infection  necessarily  depend  upon  the 
source,  ^^rulence,  and  number  of  the  organisms;  upon  the  volume 
and  nature  of  their  products — that  is,  the  toxins;  and  upon  such  local 
conditions  as  the  presence  of  foreign  bodies,  pathological  secretions,  _ 
bruised,  congested,  and  necrotic  tissues,  and  dead  spaces.  In  the  vast 
majority  of  cases  infection  is  introduced  by  the  hand  of  the  surgeon 
or  by  instruments  and  other  appliances,  and  when  so  introduced  from 
without  it  is  called  hetero-infection.  Auto-infection  is  caused  by 
organisms  existing  in  the  patient.  Some  bacteria  reach  the  wound 
through  the  air,  but  they  are  usually  not  virulent,  and  are  therefore 
not  dangerous. 

Fortunately,  the  fluids  and  living  tissues  of  the  body  have  germi- 
cidal power,  and  consequently  offer  a  degree  of  resistance  to  bacterial 
invasion.  ]Many  germs,  therefore,  which  in  artificial  media  would 
flourish,  may  become  inert  when  exposed  to  the  resistance  of  living 
tissue.  Since  this  resistance  is  often  inadequate,  it  becomes  necessary, 
so  far  as  possible,  to  exclude  the  organisms  from  the  field  of  operation 
by  aseptic  measures,  or  to  destroy  them  by  antiseptic  agents.  It  is 
clearly  important  that  the  power  of  tissues  to  resist  organisms  be 
not  impaired  by  the  too  free  use  of  chemical  antiseptics  or  mechanical 
agents. 

The  mere  acceptance  of  the  aseptic  idea  without  a  thorough  and 
systematic  application  of  it,  not  only  in  major  operations,  but  even  in 
simple  manipulations,  is  inadequate.  Efficient  technique  is  essential, 
and  is  the  outgrowth  of  a  comprehensive  grasp  and  an  intelligent 
appreciation  of  the  causes,  prevention,  and  remedies  of  septic  infec- 
tion. It  requires,  above  all,  the  development  of  what  has  aptly  been 
called  the  aseptic  conscience. 

Asepsis  is  the  absence  of  infectious  bacteria.  Strictly  speaking, 
this  may  be  an  ideal  condition,  since  it  is  not  always  fully  realized; 
but  it  is  usually  possible  to  limit  the  number  of  bacteria  to  a  safe 


SEI'TJC   ISFKCTIOX    AM)   ASEI'TIC    TKCIIMQUE  35 

iiiiiiiiiiuiii,  or  to  rriidcr  tlifiii  liariiilcss  \)\  nicaiis  of  (lru<i,s,  cliciiiicals, 
and  other  a^^'uts.  Such  ajit'iits  arc  called  antiseptics.  When  the 
antiseptic  has  the  power  to  destroy  <rcrms  it  often  is  called  a  germicide. 
Asejjsis  involves  a  great  numher  of  details  variable  and  difficult 
to  anticipate.  A  complete  description  is  impossible  and  umiecessary. 
Once  grasp  the  great  principle  of  asepsis,  and  the  subordinate  details, 
otherwise  complex,  become  simple.  The  intelligent  operator,  for  ex- 
ample, who  knows  that  septic  infection  is  the  result  of  contact,  need 
not  be  told  that  during  an  operation  he  must  keej)  liis  hand  off  from 
whatever  is  not  sterile.  The  danger  of  sepsis  is  in  a  measure  propor- 
tionate to  the  length  of  the  operation,  to  the  expo.sure  of  the  wound 
or  cavity,  and  to  the  extent  of  the  traumatism.  It  follows,  therefore, 
that  an  operation  should  be  finished  as  rapidly  and  with  as  little  oper- 
ating as  possible.  At  the  same  time,  the  slow  operator,  if  gentle  in 
his  movements,  is  less  dangerous  than  one  who  is  rapid  and  violent. 

Antiseptics 

The  therapeutic  use  of  antiseptics  is  indicated  when  infection  actu- 
ally has  occurred.  Then  the  field  of  infection,  if  local,  may  be  opened 
and  disinfected  or  drained;  if  the  infection  is  systemic,  the  internal 
use  of  antiseptic  drugs  may  be  indicated.  When  there  is  no  infection, 
and  the  use  ( f  antiseptic  drugs  is  therefore  prophylactic,  they  should 
be  used  but  sparingly,  if  at  all,  and  not  in  contact  with  the  wound. 
This  is  because  they  have  injurious  properties  which  may  give  rise 
to  dangerous,  even  fatal,  results.  The  use  of  these  drugs  is  to  secure 
surgical  cleanliness,  as  soap  is  used  to  secure  aesthetic  cleanliness;  and, 
the  object  having  been  attained,  they  should  be  washed  off  with  sterile 
water  from  the  hands  and  instruments  before  these  are  brought  in 
contact  Ts-ith  the  patient. 

The  object  of  the  prophylactic  use  of  antiseptics  is  asepsis.  Before 
any  operation  or  manipulation  the  operator's  hands,  instruments,  and 
other  appliances,  and  the  field  of  operation  or  manipulation,  should 
be  rendered  surgically  clean  and  so  maintained  throughout — the 
prophylactic  use  of  antiseptics  is  an  antiseptic  procedure  to  an  aseptic 
result. 

Antiseptic  Agents. — Among  the  antiseptics  in  most  common  use 
are: 

Soap,  Formalin, 

Carbolic  acid  and  lysol.  Alcohol, 

INIercuric  bichloride,  Heat. 

Soap,  although  not  a  strong  germicide,  is,  perhaps,  the  most  valu- 
able of  all  antiseptics.  It  is  used  for  cleansing  instruments,  clothing, 
and  other  things  needed  in  connection  with  operations,  and  for  washing 
the  skin  of  the  patient  and  operator,  but  more  especially  for  scrubbing 
the  hands  and  arms  of  the  surgeon  and  his  assistants.  The  familiar 
sapo  viridis,  usually  called  green  soap,  is  the  variety  in  general  use. 


36  GENERAL  PRINCIPLES 

Liquor  Creosolis  Comp.,  i.  e.,  lysol,  like  carbolic  acid,  is  a  chemical 
antiseptic  of  great  value.  It  also  has  high  germicidal  properties,  and 
is  used  more  freely  and  generally  than  any  other  antiseptic.  The 
danger  of  washing  out  septic  cavities  with  2  or  3  per  cent,  solutions 
is,  generally  speaking,  prohibitory;  for  example,  profound  shock  re- 
peatedly has  followed  the  introduction  of  weak  solutions  into  the 
rectum.  Ordinarily  for  vaginal  irrigation  it  is  used  in  |  to  1  per  cent, 
solution. 

Iodine  is  one  of  the  most  valuable  antiseptic  agents  and  will  be  con- 
sidered later  under  special  headings. 

Mercuric  Bichloride,  like  carbolic  acid,  is  a  germicide  of  considerable 
power,  but  is  dangerous  if  brought  freely  into  contact  with  the  patient. 
It  may  be  used  for  disinfecting  the  hands  after  prolonged  scrubbing, 
for  the  sterilization  of  surgical  dressings,  and  for  solutions  in  which 
ligatures  and  sponges  may  be  kept.  The  drug,  however,  should  be 
washed  out  of  the  sponges  with  sterilized  water  before  they  are  used. 
Irrigation  of  the  bladder  with  a  solution  as  weak  as  1 :  10,000  has  been 
followed  by  most  violent  exfoliative  cystitis.  It  should  never  be  used 
in  the  urinary  system. 

Sodium  Carbonate. — Common  washing-soda  is  an  active  germicide 
when  used  in  a  1  per  cent,  solution  with  water,  but  it  does  not  become 
active  until  the  solution  has  been  raised  to  the  boiling-point;  then 
sterilization  is  much  more  rapid  than  in  plain  boiling  water.  The  boil- 
ing solution  is  said  to  dissolve  the  capsule  of  the  germ  and  to  destroy 
it  in  five  minutes.  This  form  of  sterilization  is  suited  best  to  instru- 
ments and  other  appliances  that  are  not  injured  by  heat. 

Other  antiseptics,  such  as  formalin,  alcohol,  potassium  permanganate, 
oxalic  acid,  sulphuric  ether,  essential  oils,  turpentine,  boric  acid,  and 
nosophene,  are  useful  in  their  places  and  will  be  considered  later. 
Iodoform  may  be  rejected  because  of  its  poisonous  properties  and 
offensive  odor,  which  may  produce  protracted  nausea  and  vomiting. 

Heat. — The  actual  flame  and  the  hot-air  sterilizers  have  been  dis- 
carded for  the  most  part  in  gynecological  practice.  Moist  heat  is 
employed  in  the  form  of  boiled  water  and  of  steam. 

Sterilization  by  Boiling. — Absolute  sterilization  for  bacteriological 
work  requires  boilmg  for  thirty  minutes  on  three  consecutive  days; 
but  for  surgical  purposes  one  boiling  for  thirty  minutes  is  ample. 
Ordinary  pathogenic  microbes  are  destroyed  in  a  much  shorter  time. 

Sterilization  by  Steam  is  efficient,  available,  and  widely  applicable. 
Everything  connected  with  an  operation  that  is  not  injured  by  heat 
may  be  made  aseptic  by  this  means.  For  this  purpose,  numerous 
steam  sterilizers  have  been  devised,  that  of  Arnold  being  most  widely 
used.  It  contains  a  chamber  for  the  articles  to  be  sterilized.  The 
steam  displaces  the  air  from  this  chamber,  and  coming  in  contact  with 
the  instruments,  ligatures,  towels,  gowns,  aprons,  dressings,  and  other 
articles,  renders  them  sterile,  or  at  least  practically  safe  for  surgical 
purposes,  in  about  sixty  minutes.  The  Boeckmann  steam  sterilizer, 
which  accomplishes  so-called   "over-steam  sterilization,"  is  possibly 


SEPTIC  INFECTION  AND  ASEPTIC   TECHNIQUE  37 

niorc  cllVctixt'  tliaii  tlic  "  iiiKk'r-steam"  sterilizers  of  Arnold  and  others. 
Tlic  lioeckin.uin  sterili/.er  has  the  a(l\inita<ie  of  not  \vetlin<i;  the  dress- 
ings very  nuieh,  and  is  |)r()\ided  with  means  of  dryinfi;  them  })efore 
they  are  taken  out.  Steam  steriHzation  repeated  for  thirty  minutes 
on  tliree  eonseeutive  days  insures  tiie  final  destruction  of  any  spores 
that  miuht  otherwise  survive  the  first  exposure  and  germinate  the 
next  (hi\ . 

The  Ilii/li-ijrf',^,'it(r('  Strdiii  »S^m/izer  is  almost  indispensable  in  liosi)itals 
where  it  is  necessary  to  sterilize  rapidly  large  quantities  of  dressings 
and  other  appliances;  but  is  too  complicated  and  usually  too  expensive 
for  general  use  in  private  practice;  it  consists  of  a  large  circular  chamber 
in  which  the  articles  to  be  sterilized  are  placed  and  subjected  in  vacuo 
to  high-pressure  steam.  The  creation  of  a  vacuum  before  admitting 
the  steam  insures  greater  thoroughness  in  sterilization.  This  sterilizer 
is  furnished  in  different  sizes,  the  diameter  varying  from  fourteen  to 
eighteen  inches  and  the  length  from  twenty-two  to  thirty  inches. 

An  hustrument-case,  Low-pressure  Sterilizers,  Sponge-basins,  and  Trays 
combined,  for  Use  in  Private  Practice  are  shown  in  Figures  G,  7,  and  8. 
It  is  designed  to  lighten  the  burden  and  add  to  the  safety  of  surgical 
work  in  private  houses,  especially  in  the  country.  From  a  satisfactory 
experience  of  several  years  the  writer  offers  it  in  place  of  the  septic 
instrument-bags,  the  conventional  sterilizer,  the  cumbersome"  trays 
and  sponge-basins  which  make  up  the  usual  impedimenta  of  surgical 
practice  away  from  hospitals.  The  apparatus  fulfils  the  requirements, 
first,  of  an  aseptic  instrument-case;  second,  of  a  steam  sterilizer; 
third,  of  instrument-trays  and  sponge-basins.  It  consists  of  two  rec- 
tangular sterilizers  made  of  copper,  nickel-plated,  in  wdiich  may  be 
packed  all  instruments  and  other  appliances  requisite  for  an  abdominal 
section  or  for  any  other  ordinary  surgical  operation.  The  component 
parts  may  be  used  separately  as  pans,  sponge-basins,  and  trays.  The 
whole  outfit,  enclosed  in  a  telescope  valise,  is  sixteen  inches  long,  nine 
inches  wide,  tw^elve  inches  high,  and  when  packed  ready  for  an  opera- 
tion weighs  about  twenty-five  pounds.  Figure  6,  D.  This  case  contains 
a  complete  set  of  instruments,  towels,  sponges,  ligatures,  suitings, 
dressings,  aprons,  nail-brushes,  sterilized  green  soap,  ether,  chloroform, 
alcohol,  antiseptic  drugs,  rubber  sheet,  douche-bag,  etc.  The  equip- 
ment is  adapted  for  work  anywhere.  It  especially  solves  the  problem 
of  aseptic  surgery  outside  of  hospitals,  whether  at  the  house  of  prince 
or  pauper. 

Figure  7  represents  the  two  rectangular  copper  boxes  as  the}'  appear 
under  steam  when  used  as  sterilizers.  Observe  that  each  sterilizer 
is  supplied  with  four  legs,  which  may  be  folded  against  the  sides  of 
the  box  when  the  box  is  not  in  use  as  a  sterilizer.  Each  box  contains 
two  gauze-wire  trays,  as  showai  through  the  broken  side  of  the  sterilizer 
in  the  right-hand  cut  of  Figure  7.  The  low^er  tray  is  one  inch  above 
the  bottom  of  the  sterilizer,  and  contains  instruments.  The  upper 
tray,  resting  upon  the  lower,  contains  towels,  dressings,  ligatures,  etc. 
The  space  of  one  inch  between  the  bottom  of  the  lower  tray  and  the 


38 


GEXERAL  PRINCIPLES 


Figure  6 


-i,  ordinary  instrument-case:  B,  washable  instrument-pouch,  unrolled;  C,  pouch  rolled  and  tied; 
D  contains  combination  instrument-case,  sterilizers,  sponge-basins,  and  traj'S,  packed  and  ready  to 
be  taken  to  an  operation.  The  conventional  leather  instrument-pouch  is  a  prolific  incubator  of  disease, 
and  therefore  has  given  place  to  the  aseptic  pouch  of  washable  fabric  which  may  be  sterihzed  by  boil- 
ing and  changed  frequently.  Instrument-pouch  B  unrolled  and  C  rolled  and  tied.  A  shows  an  ordinary 
instrument-case. 

The  leather  instrument-bag  is  certain  to  become  unclean,  and  is  therefore  dangerous.  The  canvas- 
covered  telescope  valise  is  inexpensive,  practical,  and  easily  cleaned. 

Figure  7 


lUetaliic  instrument-cases  removed  from  telescope-case  and  transformed  into  two  sterihzers  under 

steam. 


Figure  S 


'^s^^m- 


The  several  parts  of  the  combination  instrument-ca.ses  being  used  as  sponge-basins,  pans,  and  trays. 


SEI'TIC   ISFFJTIOX    AM)   ASKI'TIC    TECUXKJIK  39 

bottom  of  tlu*  sterilizer  /.  r.,  Ix'low  the  line  .1  .1,  l^'iifure  7 — is  filled 
with  sterilized  water.  The  small  trays,  B  and  B,  are  filled  with  burning' 
alcohol.  These  trays  are  set  upon  saueers  to  prevent  burning  the  table- 
top.  The  burning  alcohol  converts  the  water  into  steam,  which  ster- 
ilizes the  contents  of  the  wire-gauze  trays.  One  of  the  two  detachable 
handles  resting  on  the  table  between  the  two  trays  may  be  used  to  put 
out  the  flame  by  lifting  the  small  alcohol-tray  in  contact  with  the 
bottom  of  the  sterilizer.  These  detachable  hantlles  are  designed  also 
for  use  in  separating  the  ditt'erent  parts  of  the  sterilizers  after  the 
steri  ization  is  complete. 

Finally,  the  several  parts  of  this  apparatus  may  be  utilized  as  sponge- 
basins,  pans,  and  trays.  Figure  S.  The  two  large  copper  boxes  become 
sponge-basins.  A',  A'.  The  two  top  covers  become  trays,  Y,  Y,  holding 
sterilized  water,  inside  of  which  two  of  the  gauze-wire  trays  containing 
the  instruments  are  placed.  The  gauze-trays  may  be  lifted  out  by  the 
detachable  handles  and  placed  in  the  covers  without  handling  the 
sterilized  instrimients. 

The  other  two  gauze-trays  to  the  left  of  the  sponge-basins  (Figure 
S)  hold  the  towels,  gauze,  sponges,  dressings,  and  other  things  which 
have  been  sterilized  in  them.  The  two  small,  square,  shallow  cups 
which  contained  the  alcohol  in  Figure  7  now  become  trays  for  needles, 
ligatures,  and  other  small  appliances.  Figure  8,  B  and  B.  Observe 
that  this  "sterilizer  is  quite  as  well  adapted  for  sterilization  by  boiling 
water  as  by  steam.  After  the  apparatus  has  been  under  steam  for 
thirty  minutes,  especially  if  this  process  has  been  repeated  three  times 
on  consecutive  days,  not  only  the  contents,  but  also  the  various  parts 
which  are  to  be  used  as  sponge-basins  and  trays,  are  sterilized  thor- 
oughly. Each  member  of  the  apparatus  is  supplied  with  one  or  more 
slots  or  rings,  into  which  fit  the  detachable  metallic  handles  already 
mentioned.  These  handles  are  useful  to  separate,  the  sterilizers  into  its 
several  parts  while  hot,  and  to  avoid  unnecessary  handling.  After  an 
operation,  even  upon  a  septic  case,  all  the  parts  of  the  apparatus  may 
be  washed  and  then  sterilized  by  boiling  in  a  large  wash-boiler.  The 
boiling  water  should  contain  2  per  cent,  of  sodium  carbonate. 

Sterilization  of  Supplies. — All  instruments  not  injured  by  heat  may  be 
sterilized  by  boiling  or  by  steam.  Sterilization  by  boiling  takes  only 
five  minutes  is  the  boiling  water  contains  1  per  cent,  of  sodium  carbonate. 
This  method  if  perfect  in  its  results,  even  though  the  instruments  hare 
been  used  in  a  septic  case.  Boiling  in  carbolic  acid  solution  is  no  more 
efficient,  and  it  injures  the  instruments. 

Before  and  after  an  operation  instruments,  sponge-basins,  trays,  and 
other  appliances  may  be  washed  thoroughly  in  soap  and  water  to  re- 
move the  visible  dirt,  and  then  sterilized  by  boiling  in  a  large  wash- 
boiler. 

A  good  way  is  to  sterilize  instruments  by  boiling  just  after  using, 
and  by  steam  just  before  using.  During  an  operation  the  instruments 
should  be  arranged  in  trays  and  covered,  not  with  antiseptic  solutions, 
but  with  sterile  water. 


40  GENERAL  PRINCIPLES 

Sterilization  of  Water, — Water  may  be  sterilized  by  boiling  for  thirty 
minutes.  If  not  already  clear,  it  should  be  filtered  before  boiling. 
In  aseptic  surgery  sterilized  water  is  indispensable  for  many  purposes, 
such  as  to  wash  the  hands,  to  cleanse  the  field  of  operation,  to  irrigate 
the  wound,  to  wash  sponges,  to  cover  instruments  in  the  tray,  and, 
when  indicated,  to  wash  out  the  peritoneal  cavity.  Ten  gallons  should 
be  sterilized  for  an  abdominal  section.  Hospitals  usually  are  provided 
with  receptacles  for  sterilized  water.  At  the  patient's  house  water 
may  be  sterilized  and  kept  until  the  time  of  the  operation  in  two  large 
wash-boilers,  preferably  new,  in  which  it  has  been  boiled.  It  should 
be  kept  half  hot  and  half  cold,  so  that  by  mixing,  the  right  temperature 
may  be  secured. 

Sterilization  of  Linen  and  Gauze. — Towels  should  be  of  good  quality 
and  free  from  lint;  the  so-called  glass-towels  used  for  drying  glassware 
are  best.  They  should  be  laundered  in  the  ordinary  way,  then  boiled 
in  a  1  per  cent,  solution  of  sodium  carbonate,  ironed,  done  up  in 
sterilized  linen,  and  packed  in  a  clean  tight  box.  Twenty  towels  are 
required  for  an  ordinary  abdominal  section.  Just  before  operation  they 
should  be  resterilized  by  steam. 

Gauze  Sponges  are  sterilized  by  boiling  or  by  steam,  after  the  direc- 
tions given  above  for  the  sterilization  of  towels.  They  should  be  made 
of  four  thicknesses  of  sterile  gauze,  and  should  be  six  inches  wide  by 
eighteen  to  twenty  inches  long.  Smaller  sponges  may  be  overlooked 
in  the  abdominal  cavity  and  lost,  or,  at  the  end  of  a  long  operation 
in  which  many  sponges  have  been  used,  they  may  be  difficult  to  find. 
The  frayed  edges  of  the  gauze  should  be  turned  in  and  stitched;  other- 
wise loose  threads  ma}'  stick  to  the  wound  or  be  left  in  the  cavity  and 
become  irritating  foreign  bodies.  See  precaution  relative  to  sponges 
in  Chapter  VI. 

Sterilization  of  Silkworm  Gut  and  Dressings. — Silkworm  gut  and  gauze 
dressings  may  be  sterilized  by  steam,  or  by  boiling,  or  by  both. 

Sterilization  of  Catgut. — It  is  safer  and  more  practicable  for  the  prac- 
titioner to  use  catgut  already  sterilized,  put  up  in  glass  containers 
and  ready  for  use,  which  may  be  obtained  from  pharmaceutical  houses, 
than  to  attempt  to  sterilize  the  material  himself.  Hospitals  may  prefer 
to  prepare  their  own  material. 

The  following  three  methods  are  widely  used: 

lodization  by  Claudius'  Solution. — For  general  use  in  abdominal  sur- 
gery, I  prefer  iodized  catgut  over  all  others.  The  gut,  being  loosely 
wound  on  glass  reels,  is  easily  prepared  by  soaking  in  Claudius'  solu- 
tion of  iodine  for  eight  days,  at  the  end  of  which  period  the  solution 
is  poured  off  and  the  gut  left  in  the  same  jar,  which  should  be 
sealed. 

The  solution  is  composed  of: 
Iodine  crystals,  1  part. 
Potassium  iodide,  1  part. 
Alcohol,  95  per  cent.,  50  parts. 
Water,  50  parts. 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE  41 

FoniiaJlzed  Catgut. — (1)  Soak  tlie  raw  catgut  in  stroii^i;  sulphuric  ether 
ten  (lays.  (2)  Place  in  a  40  ])er  cent,  solution  of  formaldehyde  <fjis,  for 
forty-eight  hours.  ()>)  Subject  it  to  sterile  water  irrigation,  six  hours. 
(4)  Place  it  in  95  per  cent,  alcohol  and  boil  for  twenty  minutes  on  each 
of  two  consecutive  days.  (5)  Place  in  a  solution  composed  of  bichloride 
of  mercury  one  part,  boiled  glycerin  two  hundred  parts,  and  95  per 
cent,  alcohol  one  thousand  parts. 

The  Chromic  Acid  Process. — Catgut  may  be  chromicized  as  follows: 
(1)  Soak  the  raw  catgut,  sizes  0,  1,  2,  and  3,  in  Squibb's  ether  for  four- 
teen days,  changing  the  ether  twice.  (2)  AYind  on  glass  tubes.  (3) 
Soak  in  an  aqueous  solution  of  chromic  acid  (1 :  30()())  for  fifteen  to 
eighteen  hours.  Catgut  soaked  for  eighteen  hours  will  resist  absorp- 
tion much  longer  than  that  soaked  for  fifteen  hours.  (4)  Boil  in  Merck's 
saturated  solution  of  ammonium  sulphate  for  twenty  minutes.  (5) 
Remove  from  the  ammonium  sulphate  solution  and  rinse  for  fifteen 
minutes  in  cold  sterile  water.  (6)  Preserve  in  air-tight  jars  containing 
an  alcoholic  solution  of  mercuric  chloride,  1 :  2000. 

General  Precautions. — All  varieties  of  gauze  and  all  forms  of  dressings 
should  be  sterilized  by  steam  just  before  they  are  used.  See  description 
for  dressing  abdominal  wounds  in  Chapter  VI.  The  operating-room 
should  be  clean,  well  ventilated,  well  heated,  well  lighted,  free  from 
carpets,  stuffed  furniture,  infectious  drains,  and  every  other  object 
liable  to  be  a  medium  of  infection.  Door-knobs  and  other  parts  of 
the  room,  if  liable  to  be  in  contact  with  the  hand  of  the  operator  or  his 
assistants,  should  be  covered  with  aseptic  gauze. 


The  Asepsis   of  Minor  Manipulations  and  Examinations 

Since  the  unclean  uterine  probe  repeatedly  has  caused  fatal  metro- 
peritonitis, and  since  "death  has  been  carried  to  many  a  woman  under 
the  finger-nails,"  it  follows  that  the  same  principles  which  apply  to 
surgical  work  also  hold  good  in  the  ordinary  routine  examinations 
and  local  treatment  of  the  pelvic  organs. 

Asepsis  of  the  Patient. — Sterilization  of  the  endometrium,  vagina, 
and  vulva  preparatory  to  ordinary  office  manipulation  is  impracticable, 
not  to  say  impossible.  Reasonable  safety  is  secured,  however,  by 
the  hot  vaginal  douche  which  the  patient  usually  takes  before  apply- 
ing for  treatment.  As  a  supplement  to  this  it  is  best  to  wipe  out  the 
vagina  with  dry  absorbent  cotton  on  long  lock  forceps,  and  then  with 
absorbent  cotton  saturated  with  a  5  per  cent,  solution  of  carbolic  acid 
in  glycerin,  or  with  a  1:2000  aqueous  solution  of  bichloride  of  mercury. 
Disinfection  of  the  vagina  or  vulva  in  this  way  is  especially  essential 
if  the  uterine  cavity  is  to  be  instrumentally  or  digitally  explored  or 
treated.  By  this  means  the  endometrium  is  protected  against  the 
entrance  of  septic  matter,  which  otherwise  may  easily  be  carried  in 
from  the  vulva  or  vagina  on  the  instrument — a  very  common  mode  of 
infection. 


42  GENERAL  PRINCIPLES 

Asepsis  of  the  Hands;  Rubber  Gloves. — The  cleaning  and  disin- 
fection of  the  hands  and  nails  before  and  after  the  most  ordinary 
digital  examination  are  imperative,  not  only  to  guard  against  the 
carrying  of  infection  from  patient  to  patient,  but  to  prevent  self- 
inoculation  with  specific  or  non-specific  virus  through  some-  abrasion 
upon  the  hand.  The  nails  should  be  trimmed  short;  what  has  been 
said  about  rubber  gloves  in  surgery  is  equally  applicable  here  in  the 
interest  of  the  patient  and  more  applicable  in  the  interest  of  the 
examiner.  By  the  use  of  gloves  for  examination  many  a  physician 
would  be  saved  from  the  calamity  of  specific  and  other  infections. 

Asepsis  of  the  Instruments. — The  former  practice  of  simply  washing 
instruments  in  soap  and  water  after  each  treatment  is  unsafe.  Ordinary 
washing  does  not  remove  micro-organisms.  Surgical  cleanliness  may 
be  secured  by  washing  the  instruments  in  hot  water  and  green  soap 
and  boiling  them  for  five  minutes  in  a  3  per  cent,  solution  of  sodium 
carbonate.  It  is  convenient  for  this  purpose  to  have  always  during 
the  office-hour  a  deep  tray  of  the  solution  constantly  boiling  over  the 
flame  of  a  spirit-lamp  or  a  gas-burner,  or  more  convenient  to  have 
several  sets  of  instruments,  which  may  be  used  one  after  the  other, 
and  then  all  disinfected  together  at  the  end  of  the  office-hour. 

The  Lubricant  of  Vaseline  or  Oil,  usually  kept  near  the  examination 
table,  is  unnecessary  for  lubricating  purposes  when  the  natural  secre- 
tion are  profuse  and  themselves  serve  that  purpose.  Some  artificial 
lubricant  is  always  useful,  however,  to  protect  the  operator's  fingers 
against  infection;  but  the  lubricant  is  often  a  source  of  sepsis  in  itself, 
or  it  may  easily  become  so  by  contact  with  the  unclean  finger  or 
instrument.  Gonorrhoeal  and  other  infection  frequently  is  carried 
from  patient  to  patient  in  this  way.  Neither  fingers  nor  instruments, 
therefore,  should  come  in  contact  with  the  lubricant  unless  they  are 
free  from  vaginal  and  other  secretions — unless  absolutely  clean.  The 
lubricant  should  be  aseptic  and  non-irritating.  Olive  oil  and  vase- 
line are  often  septic  and  difficult  to  wash  ofl^.  Soap  is  apt  to  irritate 
the  sensitive  vulva.  For  several  years  the  author  has  used  glycerin. 
It  is  a  most  excellent  lubricant  and  deodorant.  Even  after  digital 
examination  of  extremely  fetid  uterovaginal  cancer,  the  foul  nauseat- 
ing odor,  usually  so  lasting,  may  be  washed  off  the  examiner's  hand 
by  placing  it  under  a  stream  of  running  water,  if  before  the  examina- 
tion the  hand  was  lubricated  freely  with  glycerin.  For  this  purpose 
a  superior  quality  of  glycerin  is  required.  In  cancer  and  other  septic 
cases  gloves  should  be  worn. 

Glycerin  Emollient. — The  adaptability  of  glycerin  for  this  purpose 
has  led  to  the  preparation  of  a  glycerin  ointment.  It  is  put  up  in  soft 
metallic  collapsible  tubes,  such  as  are  used  for  vaseline  and  paints. 
The  ointment  is  forced  out  of  the  tube  by  compressing  the  bottom 
between  the  thumb  and  finger  and  folding  the  flattened  end  as  the  tube 
is  emptied.  The  use  of  the  tube  obviates  the  risk  of  contaminating 
the  lubricant  by  the  soiled  fingers.  The  preparation  is  a  sterilized 
combination  of  the  following  ingredients:  oil  of  gaultheria,  2  gm.;  boric 


Sl'rr/C    IM'FJ'TION   AM)   ASKI'TIC   TECIISlQll':  43 

acid,  -A  .u'lii.;  coni-slarcli,  SS  ,<;iii.;  pure  i;lyccriii,  NX")  ^iii.;  t  raiiacaiil  li, 
17  ^111.  'V\\v  formula  is  the  oiitcoiiic  ol'  miiiuToiis  cxixTiiiicuts  hy 
Parkr,  l)a\is  tS^:  Coiiipaiiy,  who,  upon  (lie  author's  su^-^cstion,  ha\'c 
pertV<'t(>(l  the  preparation.  It  is  furnished  hy  them  uu(h'r  tiic  name 
"(ilyeerin  iMiiollitMit." 

A  Word  of  Caution. —Many  a  disti-essiu^'  ])el\ie  infection  owes  its 
oriii'in  to  meddlesome  office  ,<;ynecol()t;'y.  Instrumental  in\asion  of  the 
endometrium  and  other  manipulations  which  recjuire  much  force  are 
procedures  which,  under  any  conditions,  may  be  far  from  triflinji'.  The 
physician's  office  does  not  furnish  for  them  a  uniformly  safe  environ- 
ment. They  require  and  should  have  the  safe<i:uards  of  tlie  home  or 
the  hospital. 

Preparation  for  an  Aseptic   Operation 

Asepsis  necessitates  a  number  of  antiseptic  proce(hires  all  looking 
to  an  aseptic  result.  The  scrupulous  preparations  about  to  be  out- 
lined for  major  operations  are  not  intended  to  imply  that  equal  care  is 
uimecessary  for  minor  operations,  because  the  latter  are  by  no  means 
free  from  danger  of  fatal  sepsis,  and  because  a  performance  seemingly 
of  minor  importance  in  the  beginning  may  end,  accidentally  or  pur- 
posely, in  opening  the  abdomen  or  in  some  other  capital  procedure. 
Traumatic  infection  of  the  peritoneum  involves  the  gravest  ■  conse- 
quences,' hence  the  need  of  extreme  precautions  in  technique;  and 
since  the  greater  may  include  the  lesser,  the  same  technique  will  suffice 
for  the  minor  procedures. 

The  recklessness  which  results  in  the  unnecessary  removal  of  pelvic 
organs  seldom  escapes  criticism.  The  recklessness  which  results  in 
the  unnecessary  introduction  of  sepsis  into  the  peritoneum  is  often 
passed  by  without  comment.  The  danger  to  life,  however,  is  determined 
less  hy  what  the  surgeon  takes  out  than  hy  what  he  yuts-in.  The  develop- 
ment of  sepsis  requires  two  conditions:  first,  pathogenic  bacteria  must 
be  present;  second,  the  way  must  be  opened  for  them  to  enter.  Experi- 
ment has  shown  that  they  may  be  transmitted  even  through  the  un- 
broken skin  or  mucous  membrane,  but  that  traumatism  makes  an  open 
door.  Pathogenic  bacteria  have  their  source,  first,  in  the  operator 
or  his  assistants;  second,  in  the  instruments  and  other  appliances; 
third,  in  the  patient.  The  antiseptic  procedures  to  an  aseptic  result 
therefore  must  be  these: 

1.  Preparation  of  the  operator  and  his  assistants. 

2.  Preparation  of  the  patient. 

1.  Preparation  of  the  Operator  and  His  Assistants. — The  operator 
and  assistants  should  be  in  good  health,  and,  since  the  breath  may  be 
a  medium  of  infection,  they  should  especially  be  free  from  nasal  catarrh 
and  coryza.  Disorders  of  nutrition  which  involve  deficient  elimination 
through  the  bow^els  and  kidneys  may  throw^  that  function  upon  the 
lungs,  and  cause  the  breath  to  be  loaded  with  fetid  products,  an 
undoubted  source  of  infection.  The  bacteria  of  saliva  may  be  most 
infectious;  hence  unnecessary  talking  over  the  field   of  operation  is 


44  GENERAL  PRINCIPLES 

objectionable,  for  small  particles  of  saliva  and  its  bacteria  may  reach  the 
wound.  Experience  has  shown  that  an  orator  in  speaking  may  throw 
particles  of  saliva  thirty  feet  into  the  audience.  The  necessity,  there- 
fore, of  protecting  wounds  and  open  cavities,  by  means  of  a  mask, 
against  the  germ-laden  breath  of  the  operator  and  assistant  is  apparent 
and  urgent.  A  mask  of  ten  layers  of  gauze  tied  over  mouth  and  nose 
is  effective;  fewer  layers  have  been  found  inadequate.  A  striking 
case  in  point  is  the  following  :  A  colleague,  while  operating  for  varicose 
vein  of  the  leg,  noticed  a  slight  particle  of  saliva  thrown  into  the  wound 
from  the  mouth  of  his  assistant,  whose  saliva,  on  examination,  was 
proved  to  contain  streptococci.  The  patient,  despite  most  careful 
antiseptic  care,  died  of  streptococcus  infection. 

Let  the  nails  be  cut  short;  long  nails  retain  quantities  of  dirt  which 
any  amount  of  scrubbing  may  fail  to  dislodge.  They  are  also  a  possible 
cause  of  unnecessary  irritation,  not  to  say  traumatism,  and  may  there- 
fore be  both  the  carriers  of  poison  and  the  instruments  for  its  inocula- 
tion. The  shorter  the  hair  the  less  dirt  will  there  be  to  fall  from  it  into 
the  wound.  The  hair  and  scalp  must  be  kept  clean  by  frequent  washing 
and  brushing.  The  long,  full  beard  is  an  unnecessary  source  of  danger; 
the  less  beard  the  better. 

The  daily  bath  is  an  important  part  of  the  routine  of  aseptic  sur- 
gery. Special  clothing  made  of  washable  material  is  desirable;  for 
women  the  usual  costume  of  the  trained  nurse,  and  for  men  trousers 
and  shirts  or  short  coats.  Special  clothing  for  operation  has  a  three- 
fold advantage.  It  protects  the  operator  from  taking  cold  after  leaving 
the  operating-room  in  his  ordinary  clothing,  which,  if  worn  during 
the  operation,  might  be  wet  with  perspiration.  It  saves  the  ordinary 
clothing  from  contamination  when  the  operation  is  upon  a  septic  case. 
It  is,  above  all,  an  antiseptic  measure  in  the  interest  of  the  patient. 

Sterilization  of  the  Hands  and  Arms. — Formerly  the  extreme  mortality 
of  abdominal  sections  was  due  in  great  part  to  direct  infection  from 
the  hand  of  the  operator.  To  wash  the  hands  rapidly  in  soap  and  water 
and  then  to  dip  them  in  some  antiseptic  solution,  a  not  uncommon 
practice  even  now,  gives  Httle  protection  against  infection.  Absolute 
sterilization  of  the  skin  without  injuring  it  is  ideal  but  impossible. 
Practical  asepsis,  however,  is  possible.  To  bring  this  about  numerous 
antiseptics  have  been  used;  by  antiseptics  are  meant  antiseptic  drugs 
and  antiseptic  measures.  Of  these,  prolonged  scrubbing  with  green 
soap  sterilized  by  heat  and  with  hot  water  is  the  most  effective.  A 
mixture  of  alcohol  and  sulphuric  ether,  which  have  germicidal  prop- 
erties, each  one  part,  with  four  parts  of  green  soap,  makes  a  valuable 
liquid  antiseptic  soap.  The  green  soap  should  be  of  good  quality  and 
previously  sterilized  by  heat.  Beat  one  pound  of  this  soap  in  a  recep- 
tacle with  two  ounces  of  alcohol  until  uniformly  smooth.  Transfer 
to  a  glass  bottle  of  at  least  three  pints'  capacity  and  add  two  ounces 
of  ether.  Cork  well,  agitate,  and  set  aside,  for  two  hours.  Then  add, 
with  thorough  shaking,  two  ounces  each  of  ether  and  alcohol  previously 
mixed.    The  scrubbing  of  the  hands  and  forearms,  to  be  effective,  must 


SEPTIC  INFECTION  AND  ASEPTIC   TECHNIQUE  45 

be  in  soap  and  water  as  hot  as  can  be  borne  without  positive  discom- 
fort. Heat  is  a  vahiable  aid  in  the  removal  of  dirt.  Scrubbing  must  be 
thoroufi'li  and  vigorous  and  prolonged.  The  longer  the  scrub})ing  the 
more  difficult  it  is  to  cultivate  bacteria  from  the  scrapings  of  the  skin. 

Prolonged  Scrubbing  makes  the  hands  safe,  not  so  much  by  the 
destruction  as  by  the  mechanical  removal  of  bacteria.  They  are  re- 
moved together  with  the  secretions  of  the  skin  and  other  foreign 
matter  upon  which  bacteria  flourish.  To  scrub  the  hands  and  fore- 
arms, always  use  a  very  large  brush,  preferably  without  handle.  The 
large  brush  is  indispensable;  it  cannot,  however,  be  made  to  reach 
those  strongholds  of  bacteria  so  often  overlooked  or  neglected,  the 
angles  between  the  fingers;  to  scrub  out  these  angles  thoroughly,  use 
a  brush  with  a  handle  of  ordinary  size,  but  do  not  attempt  to  scrub 
the  other  parts  of  the  hands  and  the  arms  with  such  a  brush;  it  is  too 
small.  Destroy  all  brushes  that  have  been  used  in  septic  cases.  Brushes 
not  in  actual  use  should  be  made  aseptic  and  kept  in  aseptic  gauze  or 
towels. 

Alcoholic  Solution  of  Mercuric  Bichloride. — After  scrubbing  with 
green  soap  or  the  liquid  antiseptic  soap  just  mentioned,  wash  off  all 
trace  of  soap  with  clean  water.  Then  wash  with  1 :  3000  solution  of 
mercuric  bichloride  in  70  per  cent,  alcohol.  Frequent  washing  of  the 
hands  and  arms  in  this  solution  as  often  as  they  become  dry  for  a 
period  of  ten  minutes  is  more  practical  and,  therefore,  more  likely  to 
be  carried  out  effectively  than  the  usual  soaking  for  an  equal  length 
of  time.  Aqueous  solutions  sterilize  less  surely  and  less  quickly  and, 
therefore,  are  unnecessary  for  hand  sterilization  if  this  alcoholic 
solution  of  mercuric  bichloride  be  used. 

Rubber  Gloves. — Rubber  gloves  serve  as  protection  alike  to  the 
operator  and  the  patient,  and  in  all  abdominal  operations  should  be 
worn  by  all  persons  whose  hands  are  brought  into  relation  directly  or 
indirectly  with  the  field  of  operation.  After  an  operation  they  may 
be  sterilized  by  boiling,  and  used  again.  Only  two  plausible  objections 
to  the  use  of  the  gloves  have  been  raised;  first,  that  the  hands  can  be 
sterilized  adequately,  and  that  the  gloves  are  therefore  unnecessar}-; 
second,  that  they  impede  the  operator  to  such  an  extent  as  to  increase 
rather  than  diminish  the  danger  of  the  operation.  The  reason  for  the 
first  objection  is  not  true;  but  if  it  were  true  that  the  hands  can  be 
sterilized  adec{uately,  it  by  no  means  follows  that  they  always  will  be. 
The  second  objection,  that  gloves  impede  the  operator  to  any  consider- 
able degree,  can  be  urged  by  no  one  unless  he  would  thereby  give  such 
evidence  against  his  own  dexterity  as  will  raise  the  question  of  his 
fitness  for  surgical  work.  Gloves  may  be  dispensed  with  in  exceptional 
cases  when  very  rapid  work  is  of  vital  importance.  The  use  of  the  glo\'es 
should  in  no  respect  lead  to  relaxation  in  the  sterilization  of  the  hands, 
for  they  may  be  cut  or  punctured  during  an  operation,  in  which  case, 
however,  they  should  be  replaced  immediately  by  fresh  ones. 

Clothing. — A  gauze  about  the  operator's  head,  if  brought  ^^^ll  down 
over  the  forehead,  guards  the  wound  from  fine  particles  of  dirt  which 


46  GENERAL  PRINCIPLES 

otherwise  might  fall  from  the  hair.  Sterile  gowns,  trousers,  and  tennis 
shoes  are  in  common  use.  A  mask  of  several  layers  of  gauze  should 
be  worn  over  the  mouth,  nose,  and  beard.  Gowns  and  other  clothing 
should  conform  to  the  recognized  requirements  of  aseptic  surgery. 

2.  Preparation  of  the  Patient. — The  antiseptic  preparation  of  the 
patient  has  a  twofold  purpose:  First,  to  remove,  destroy,  and  limit 
the  power  of  pathogenic  bacteria;  this  requires  the  local  application 
of  antiseptic  measures  to  the  abdomen,  external  genitals^  and  vagina. 
Second,  to  enable  the  patient  to  resist  any  bacteria  that  may  remain 
or  develop.  This  may  require  both  regulative  and  medicinal  treat- 
ment. A  searching  general  examination  from  the  standpoint  of  internal 
medichie  should  be  made  in  every  case.  This  examination  may  show 
phthisis  or  diabetes,  or  some  other  contraindication  or  condition  which 
would  make  the  operation  extraperilous.  Then  the  preparatory  treat- 
ment should  be  directed  to  that  condition.  To  be  forewarned  is  to  be 
forearmed. 

When  the  operation  is  not  one  of  emergency  the  preparation  may 
well  include  several  days  of  observation  and  treatment.  In  this  way 
often  the  patient's  peculiarities  may  be  measured,  and  her  power  to 
resist  infection  may  be  increased.  The  abdominal  and  thoracic  organs 
should  be  examined,  especially  the  lungs,  heart,  and  kidneys.  A  quan- 
titative examination  of  urine  may  show  a  deficiency,  for  example,  of 
urea;  then  a  few  days  of  judicious  diet  and  diuretics  may  turn  the 
result  of  an  operation  in  the  patient's  favor.  The  daily  general  bath, 
with  friction,  besides  being  an  antispetic  measure,  increases  the  action 
of  the  skin  and  relieves  the  kidneys. 

The  drinking  of  water  in  large  quantities  during  the  week  before  a 
capital  operation  is  most  advantageous  and  when  practicable  never  to 
be  neglected.    Three  or  four  pints  a  day  should  be  taken. 

Bowel  distention^  impedes  the  operator  and  lengthens  the  operation. 
It  is  a  dangerous  complication  both  during  and  after  the  operation, 
and  is  the  cause  of  a  great  deal  of  mortality.  So  far  as  practicable, 
then,  let  the  bowels  be  emptied  of  gases  and  solids  and  of  whatever 
may  ferment  and  form  gas.  Experiment  has  shown  that  the  countless 
myriads  of  bacteria  habitually  present  in  the  intestine  may  be  reduced 
by  catharsis  and  intestinal  antiseptics  to  a  relatively  insignificant 
number;  hence  the  following  measures  are  suggested  to  render  the 
bowels,  as  nearly  as  possible;  aseptic: 

1.  For  several  days  before  the  operation  exclude  all  food  that  is  apt 
to  ferment. 

2.  On  the  third  night  before  the  operation  give  five  grains  of  blue 
mass.  If  the  bowels  do  not  act  freely  the  next  morning,  give  an  ounce 
of  castor  oil.  On  the  day  before  the  operation  give  a  Seidlitz  powder 
or  some  other  active  saline  purge.  Two  compound  cathartic  pills  may 
be  substituted  for  the  blue  mass.  Repeat  the  cathartics  if  necessary. 
A  large  dose — 2  ounces — of  castor  oil  one  or  two  days  before  the 
operatioil  is  most  satisfactory  and  may  take  the  place  of  all  other 
cathartics. 


SEPTIC  INFECTION  AND  ASEPTIC   TEC/IMQCE  -^l? 

o.  (ii\c  repeated  high  copious  enemas  (hiriii<;-  the  two  da.'.s  ])efore 
the  operation.  The  enemas  may  l)e  of  soapsuds,  each  j)int  containing;, 
thoroughly  mixed,  a  drachm  of  turpentine.  rerse\(  re  in  this  until 
no  considerable  amount  of  f>as  remains,  if  the  turpentine  and  soapsuds 
enema  does  not  suffice,  try  a  mixture  c()ntainin<i;  two  ounces  each  of 
glycerin,  Epsom  salts,  and  water.  Use  a  flexible  rectal  tube  wnth  firm 
walls,  thre(>  feet  long,  and  give  the  enema  as  high  as  ])ossi})le. 

Clsansing  the  Field  of  Operation. — Every  abdominal  section  may 
require,  for  drainage  or  for  other  reasons,  that  an  opening  be  made 
from  the  peritoneal  cavity  into  the  vagina;  hence  the  necessity  of 
cleansing  not  only  the  abdominal  wall,  but  also  the  vaginal  surfaces 
an<l   external  genitals. 

Ahdjuiinal  Preparation. — Twenty -four  hours,  or,  if  jjossible,  forty- 
eight  hours  before  operation,  the  entire  abdominal,  pubic,  and  perineal 
areas  are  sha^•ed  carefully,  including  not  only  the  coarse  hair,  but, 
so  far  as  possible,  the  white  downy  hairs,  especially  those  about  the 
navel.  A  poultice  of  liquid  antiseptic  soap,  already  described,  is  then 
placed  o\'er  the  abdomen,  including  the  epigastriiun,  and  allowed  to 
remain  one  and  one-half  hours;  upon  the  removal  of  this  poultice  the 
remaining  soap  is  washed  off  first  with  sterile  water,  anrl  then  with 
commercial  ether.  The  abdomen  then  is  covered  with  a  thick  layer 
of  gauze  wet  with  an  aqueous  mercuric  bichloride  solution,  1:3000, 
the  whol"e  being  covered  with  oiled  muslin  or  gutta-percha  and  an  ab- 
dominal binder.  This  dressing  is  rewet  every  four  hours  and  retained 
imtil  twelve  hours  before  the  operation,  when  dry  sterile  gauze  is 
substituted  and  retained  until  the  patient  is  under  antiesthesia.  This 
last  dry  dressing  then  is  removed  and  the  abdominal  and  pubic  regions 
are  painted  with  a  solution  of  iodine,  a  particular  application  being 
made  to  the  umbilical  and  pubic  regions,  to  wdiich  a  second  coat  should 
be  applied.  In  emergency  cases  the  abdomen  is  prepared  as  above  just 
prior  to  the  operation,  but  since  there  has  been  no  pre^'ious  cleans- 
ing, the  parts  should  be  thoroughly  scrubbed  wdth  the  iodine  solution. 
This  solution  consists  of  iodine  crystals,  seven  parts;  potassium  iodide, 
five  parts;  and  95  per  cent,  alcohol,  eighty-eight  parts. 

The  rationale  of  preparing  a  large  area  w-hen  only  a  small  portion 
of  the  abdomen  is  to  be  incised  is  that  in  some  cases  the  incision  may 
have  to  be  extended  greatly  so  that  skin  surfaces  w-hich  one  has  no 
previous  idea  of  handling  may  come  in  contact  with  the  hands  or 
gloves.  A  process  so  extensive  and  detailed  as  this  may  seem  ininecessari/, 
hut  there  is  proof  that  it  almost  entirely  prevents  wound-infection  and 
stitch-hole  abscesses. 

Preparation  of  the  Vagina. — The  mons  veneris  and  \'uh'a  ha\-ing 
been  shaved,  three  vaginal  douches  are  to  be  given  on  each  of  the  three 
consecutive  days  before  the  operation.  Each  douche  should  consist 
of,  first,  strong  soapsuds  made  of  green  soap;  second,  sterilized  water; 
third,  solution  of  bichloride  of  mercury,  1:3000. 

Just  before  beginning  an  operation,  when  the  patient  is  under  the 
anesthetic,    the   external    genitals   and    surrounding   parts   should    be 


48  GENERAL  PRINCIPLES 

scrubbed  thoroughly  with  a  large  sterile  towel,  and  the  vagina  should 
be  scrubbed  and  swabbed  out  with  a  wad  of  gauze  in  the  grasp  of  a 
long  hsemostatic  forceps.  Sterilized  green  soap  or  the  liquid  antiseptic 
soap  already  described  should  be  used.  All  soap  should  now  be  washed 
away  by  a  stream  of  sterilized  water  poured  from  a  pitcher,  and  the 
parts  further  sterilized  by  filling  the  vagina  with  a  1 :  3000  70  per  cent, 
alcoholic  solution  of  bichloride  of  mercury.  Finally  the  vagina  should 
he  'packed  loith  a  continuous  strip  of  gauze  saturated  with  the  same  solution; 
this  packing  should  remain  in  the  vagina  during  the  operation  unless  it 
becomes  necessary  to  open  from  the  peritoneum  into  the  vagina,  in  which 
case  the  gauze  should  he  removed;  it  insures  asepsis  of  the  vagina  and  is 
a  precaution  of  the  utmost  moment,  in  view  of  the  possibility  of  opening 
from  the  pelvic  cavity  into  the  vagina. 

Figure  9 


Practical  substitute  for  the  Kelly  pad. 


Aseptic  Surgical  Precautions 


It  is  wise,  especially  in  a  case  of  infectious  endometritis,  to  curette 
and  disinfect  the  endometrium  before  proceeding  to  open  into  the 
pelvic  cavity.  This  precaution  may  prevent  post-operative  infection 
in  the  pelvic  cavity  by  extension  from  the  uterus. 


SEI'TIC   IM'ECTKJX   AM)   ASEPTIC    TECIlSlQiK  4'J 

111  the  giving  of  the  douche  the  famihar  I\ell\'  pad  will  be  found  more 
useful  and  more  practical  than  the  bed-pan.  The  objections  to  this 
pad  are,  first,  that  it  is  not  always  obtainable;  second,  it  is  difficult 
to  keep  clean,  and  is  therefore,  ft)r  surgical  j)urposes,  apt  to  be  septic. 

The  writer  uses  a  i)ractical  substitute  for  the  Kelly  jjad  that  obviates 
both  objections.  It  is  simply  a  piece  of  sheet  rubber,  three  feet  wide 
and  four  and  one-half  feet  long.  The  rubber  sheet  at  its  upper  end 
and  sides  is  folded  over  rolls  of  towelling  or  muslin,  so  that,  as  in  Kelly's 
pad,  the  water  will  be  directed  into  the  bucket  below.  See  Figure  9. 
Rubber  sheeting  is  available  everywhere,  is  cleaned  ea.sily,  and  is  so 
inexpensive  that  it  may  be  renewed  frequently.  Sheeting  which  has 
the  rubber  finish  on  both  sides  is  preferable.  The  ordinary  oil-cloth 
used  to  cover  a  kitchen  table  is  serviceable,  and  may  be  obtained  in 
almost  every  house. 

Protection  for  the  Feet  and  Legs. — When  the  patient  is  placed  on  the 
table  before  the  anaesthesia  begins,  it  is  well  to  co\er  her  feet  and  legs 
with  long  sterilized  flannel  stockings. 


CHAPTER  III 

DIAGNOSIS 

The  subject  of  diagnosis  is  divided  into  two  parts:  first,  the  clinical 
history;  second,  the  physical  examination. 

THE   CLINICAL   HISTORY 

Before  asking  questions  or  recording  any  of  the  history  it  is  well  to  let 
the  patient  make  her  own  statement  without  suggestion ;  this  will  relieve 
her  of  nervousness  and  compose  her  mind  for  the  systematic  questioning. 

Histories  usually  are  kept  in  blank  case-books  printed  and  bound 
for  the  purpose.  A  very  practical  way  is  to  keep  them  in  individual 
envelopes,  made  of  strong  manila  paper,  each  history  in  an  envelope 
by  itself,  with  the  name,  residence,  and  date  of  the  first  visit  written 
across  the  end.  The  histories  are  kept  in  alphabetically  arranged 
pigeon-holes,  where  they  may  be  found  readily.  The  great  advantage 
of  this  plan  is  that  the  histories  may  be  written  away  from  the  office 
on  scraps  of  paper,  and  do  not  have  to  be  copied,  but  may  be  filed 
away  together  with  any  subsequent  correspondence,  prescriptions,  or 
additional  notes. 

Form  for  Record  of  Cases. — The  skeleton  form  given  on  the  fol- 
lowing pages  is  suggested  for  the  convenient  and  systematic  record  of 
cases.  The  printed  blank  is  subject  to  such  erasures  and  additions  as 
the  individual  case  may  require.  In  using  such  a  blank  one  must 
keep  in  mind  the  fact  that  no  stereotyped  form  can  include  sugges- 
tions for  all  the  points  that  are  liable  to  come  up  in  connection  with  a 
case.  Unless,  therefore,  one  supplements  the  inquiry  by  such  ques- 
tions as  each  special  case  may  call  for,  he  will  fall  into  a  dangerous 
routine. 

The  record  form  which  follow^s  will  help  the  student  and  young 
practitioner  to  form  the  habit  of  accurate  and  systematic  diagnosis. 
As  one  gains  experience  and  automatic  grasp,  and  judges  less  from 
multiform  details  and  more  from  principles,  he  will  eliminate  grad- 
ually from  his  histories  and  records  all  that  is  not  essential  to  the 
efficient  analysis  of  his  cases.  A  few  general  statements  then  may 
serve  the  purpose  of  a  practical  memorandum. 

In  recording  a  case  one  may  use  conveniently  abbre\'iations  and 
signs,  for  example,  the  plus  sign  (  +  ),  the  minus  sign  (  — ),  the  plus  or 
minus  sign  (±),  the  zero  sign  (0),  the  sign  of  equality  (  =  );  and  the 
letter  n  may  signify  (  +  )  excessive,  (  — )  less  than  normal,  (±:)  variable, 
(0)  no,  none,  or  negative  results,  (  =  )  equals  or  amounts  to,  (n) 
(50) 


DIAGXOSIS  51 

normal;  v.  s.  =  0  would  be,  for  example,  a  short  expression  to  indicate 
the  absence  of  vesical  symptoms. 

The  hypothetical  case  outlined  in  the  history  blank  is  lujt  out  of 
the  common.  The  patient  harl  been  a  well-developed  w(mian,  of  good 
family  history.  The  menstrual  and  other  functions  ha<l  been  perfectly 
normal  until  after  the  first  child  was  born.  Then  came  the  abnormal 
developments  recorded  in  sections  (5  to  19.  Neglected  lacerations  of 
the  cervix  and  perineum  opened  the  door  for  the  entrance  of  infec- 
tion; hence  infection  spread  through  the  endometrium  and  possibly 
also  through  the  parametric  lymphatics  and  veins  to  the  tubes,  ovaries, 
and  adjacent  peritoneum.  Adhesions  formed,  binding  the  uterus 
with  its  appendages  together  in  posterior  displacement;  this  displace- 
ment was  increased  and  perpetuated  by  the  excessive  weight  of  the 
uterus,  by  impairment  of  support  from  the  lacerated  perineum;  that  is, 
from  injury  to  the  pelvic  floor  and  from  the  now  relaxed,  subinvoluted 
state  of  all  the  pelvic  organs  and  their  supports. 

P>ndometritis  and  metritis  give  rise  to  menorrhagia  and  leucorrhoea, 
which  explains,  partly  at  least,  the  antemia,  neurasthenia,  nervous  irri- 
tation, and  impaired  general  nutrition.  Difficulty  of  walking  and 
standing,  both  from  general  weakness  and  from  displacement  of  the 
pelvic  organs,  interferes  with  necessary  exercise,  and  still  further  adds 
to  the  causes  of  malnutrition.  The  increased  frequency  of  urination 
when  the  patient  is  on  her  feet  may  be  explained  by  the  fact  that  the 
organs  at  that  time  descend  to  a  lower  level  and  drag  on  the  bladder. 
Intestinal  indigestion,  sluggish  liver,  faulty  metabolism,  constipation, 
deficiency  of  urea  and  of  other  urinary  solids,  excess  of  uric  acid,  and 
finally  chronic  interstitial  nephritis,  are  associated  not  uncommonly 
with  peh-ic  traumatism  and  infection. 

The  difficulties  of  gynecological  diagnosis  often  are  increased  by  the 
fact  that  pelvic  lesions  may  exist  and  cause  no  definite  local  symptoms. 
Even  greater  confusion  may  arise  from  the  presence  of  pelvic  symp- 
toms which  are  caused  not  by  peh-ic  but  by  extrapehdc  disorders. 

.  The  nerve  counterfeits  of  pehnc  disease  are  most  realistic  and  be- 
wildering, and  have  been  expressed  well  in  the  following  paragraphs 
by  the  late  William  Goodell: 

"Xerve-strain,  or  nerve  exhaustion,  comes  largely  from  the  frets, 
the  griefs,  the  jealousies,  the  worries,  the  bustles,  the  carks,  and  cares 
of  life.  Yet,  strangely  enough,  the  most  common  symptoms  of  this 
form  of  nerve  disorder  in  women  are  the  very  ones  which  lay  tradi- 
tion and  dogmatic  empiricism  attribute  to  ailments  of  the  womb. 
They  are,  in  the  usual  order  of  their  frequency,  great  weariness  and 
more  or  less  nervousness  and  wakefulness,  inability  to  walk  any  dis- 
tance, and  a  bearing-do"UTi  feeling;  then  headache,  napeache.  and 
backache.  Next  come  scanty,  or  painful,  or  delayed,  or  suppressed 
menstruation,  cold  feet,  and  irritable  bladder;  general  spinal  and 
pelvic  soreness  and  pain  in  one  ovary,  usually  the  left,  or  in  both 
ovaries.  The  sense  of  exhaustion  is  a  remarkable  one;  the  woman  is 
always  tired;  she  spends  the  day  tired,  she  goes  to  bed  tired,  and  she 


52  GENERAL   PRINCIPLED 


RECORD  OF  A  CASE; 

ABBKEVIATiONS:    The  sign  +  signifies  excessive;  -,  less  than  normal;  v,  variable;   0,  no,  none  or  negative  res-i!ts; 
^  /y       ^'  signifies  normal. 

M/2^M^d^. /^^^tWC, w^,^-«...Z4^^^  ...>^^i^^.....Ak^^.'. 

A^eHO-Dale  of  first  consultation  ■COi^A-^''<^^_J'/ //^^O^    

Recommended  by  .2}.x:^J/}rt£Z<J,aL'tj^      Phc.JXL<4<4^f^..u _ „... 

J.  ^3!aoD2Ciiiyl4AM>^Oy'''^:a^  Dates  illness  from 

2..Si»g!e,  Married,  Wijujw /  Uf  -years.    3.   \Vell,rH developed.    NHirijicn g»Hi anemic, pUfhofk. 
4,  Family  History  t-- 


5.  Menseflf    First  menses  at  age  /^  .     ,<lim^ys,  usually  regular,  h'r  'f;itlttr,  every leJZa.days ; 

continuesp...f...lo.J  J  .^ays.     Amount,    tisstm^ii,,    jmnjl,    large,    cMA'J.      ..'y^....  Color.     Last 
•j/tr:X.^;..^tJl*^4/v<^.    i  ended  ../Iw^    /-^^  7^//? 


menses  i 

6.  Dvsmenorrtioea :      /      fain  inguinal,  riglit  and  left,  shooting  down -thighs,  hypogastric, 

lumbar,  bearing  down,    constant,    f^miittiH  f,  hi  lt»<m  it  ton  f.     V.i^-fi.^it^i.^ tf>>rC dayf"— 

before,  Ci/^^^^- during,  •      i  itficrfiow.     In  bed /jL.    days. 


7.  Intermenstrual  Pain: 

£«vgM\}nl,  jjinwAiM/i  mitn'iniih^ni,  iimii'tini ^ li'alk^ig  atid  especially  standing 

cause  bearing  down,  sensation  and  exhaustion ..,. T'.'ti.  ^^^c^.-*^  (?T''^^-''^X4.y(^*^AMl^a.^i 

8,  Ctildren:  Number-^- :  oldest  -.^-- ; youngest— -i^-.    Labors  um-mul,  rapid,  iiriioiif 


{^^l^^^'Ci^r'^-^^'S^X,^^  bed.^....weeks.     Getting  up  ««^  iUr^.ir^^-ph^ 

9.  Abortions:  Number. .X~.-.  ;  first  at  ^montlU ;  last  at--^.. -months.    Jnbed-J—.-iuecks.C^-'C^i^^^^^'-^t 

JO.  Leucorrhoea :    First  appearance-    y-f4'^i<^^^^^-— ago.     BJeedy^  pufnUnt\  muco-purulent,  wiiiDirj, 
/A.v/.^  ■'^ifn,  m■'^^'\■\  d\\r\h  glairy,  offensive.      Constant  worse  before,  sm-ing,  after  menstruation. 


1 1.  Bladder  Symptoms :    Jfclyuitia,  tmepiiti/imift  reli-fiiio'ii  dysurm.     Urinates--^:Jh-times  during  night, 

\  r  ihiif^  during  day.     Frequency  rte*  increased  by  standing  or  walking 

12.  Digestion:     Teeth .r^-V» /  a6ietite--  —4~^-   .   eating  causes       '    l   \ distress,  distention, 

nausea,    '.■r"rtr"g.    eructation,  flatule7ice, Acidity,    imiviedialglj',  an  hour  or  two   after  eating. 
Regular  habits  of  eating.      Kinds  of  food Cc-'^'-^. ,  tea,  coffee,  ti.ki>h\jL 


13.    Bowels:     j'i'ij;iu'ui«,  constipation  and  diarrhaa,  alternating.    .-Iction  fnH,  scanty,  ■Ufa*/!,  offensive, 
bloody,  I'micous,  purnhnh    Painful  at  times  in  pelvis,  at  anus.       ColUT- 


DlA(,'xns/s  53 


14.  N.TVOUS  System  :     S/fe/:t  ^      0<-^-^r^^ Uy^r^ia,  /.i ft-;)-,  nmviisneis.  tifurastfitnia. 

15.  Extra  Pelvic  Organs:    ^'  '^^f^^ij^ in.\^    Jl   ~ttiX J<-i-^C^( ^      iytH^iytT^.^.^ 

16.  Previous  Illnesses:       '^/  ^'(U.  ^    Cy  cS^l^ 


y  e.c^^iyf~~z^ 


18.  Previous  Treatment:  /UJ^2^<^;<*-^-^P^'-'^^^ 


J9.  Urinalysis :    Ai/iounlpi  s^ /loms-^.O...^ Sp.  gr.l  O.P  S  ^    Reaclioii 0^  ' 

Color'.yS^-'^iwtAlbiiiiie,! Or...  ^iigar -.O.......   Urcu /■'/Y '^    ToUtI  SoliJi  ^  {^ ' 

SedimcnAy  lc»Urf,,s^/i£i^'iA~ Microscopical  Examination /'TL^ ^^''^^'r^^^^t^  . 

20.   Physical  Examination,  Diagnosis  and  Treatment; 

C,  '  Jic^Cuu^-''^^-^  /[    Cox^trxqi:  U^tZ^'  a^^i_  ^r<X^f^ t<x.C^-uU^ 

£  ,  liXoT^x^  ayjAe^X^j.^  ^yiiZCj  i^c^^)  Uvcoa^i/i^  (u^^ 


54  GENERAL  PRINCIPLES 

wakes  up  tired — often,  indeed,  more  tired  than  when  she  fell  asleep. 
She  sighs  a  great  deal;  she  has  low  spirits,  and  she  often  fancies  that 
she  will  lose  her  mind.  Her  arms  and  legs  become  numb  so  frequently 
that  she  fears  palsy  or  paralysis.  Nor  does  the  skin  escape  the  general 
sympathy.  It  becomes  dry,  harsh,  and  scurfy,  and  pigmentary  deposits 
appear  under  the  eyes,  around  the  nipples,  and  in  the  chin  and  forehead. 
The  symptom-group  of  nervous  exhaustion — anaemia,  backache, 
bearing-down,  difficult  walking,  ovarian  pain,  and  menstrual  disorders 
— although  often  without  the  least  gynecological  significance,  is  usually 
the  signal  for  a  gynecological  diagnosis.  Any  pelvic  organ  showing 
the  slightest  irregularity  is  singled  out  as  the  culprit  and  promptly 
placed  on  trial.  Endless  injurious  local  treatment  and  grave  surgical 
operations  may  now  cause  the  woman  to  suffer  many  things  from  many 
physicians." 

As  Goodell  aptly  remarks:  "If  no  tangible  disorder  of  the  sexual 
organs  be  discoverable,  the  invisible  endometrium  or  ovaries  must  take 
the  blame  and  receive  the  local  treatment.  Whatever  the  inlook  or 
the  outlook,  a  local  treatment,  more  or  less  severe,  is  liable  to  be  the 
issue.  Yet  these  very  exacting  symptoms  may  be  due  wholly  to  nerve- 
strain,  or,  what  is  synonymous,  to  loss  of  brain-control  over  the  lower 
nerve  centres,  and  not  to  direct  or  to  reflex  action  from  some  supposed 
uterine  disorder.  Neither,  for  that  matter,  may  they  come  from  some 
real,  tangible,  and  visible  uterine  lesion  which  positively  exists.  Thus 
it  happens  that  a  harmless  anteflexion,  a  trifling  leucorrhoea,  a  slight 
displacement  of  the  womb,  a  small  tear  in  the  cervix,  an  insignificant 
rent  of  the  perineum,  or,  what  is  almost  always  present,  an  ovarian 
ache,  each  plays  the  part  of  the  will-o'-the-wisp  to  allure  the  physician 
from  the  bottom  factor.  To  these  paltry  lesions — because  they  are 
visible,  palpable,  and  ponderable,  and  because  he  has  by  education 
and  by  tradition  a  uterine  bias — he  attributes  all  his  patient's  troubles; 
whereas  a  greater  and  subtler  force,  the  invisible,  impalpable,  and 
imponderable  nervous  system  may  be  the  sole  delinquent.  The  suf- 
ferer may  be  a  jilted  maiden,  a  bereaved  mother,  a  grieving  widow,  or 
a  neglected  wife,  and  all  of  her  uterine  symptoms — yes,  every  one  of 
them — may  be  the  outcome  of  her  sorrows  and  not  of  her  local  lesions. 
She  is  suffering  from  a  sore  brain  and  not  from  a  sore  womb." 

We  may  admit  the  extreme  wisdom  of  Goodell's  summing  up;  at 
the  same  time  we  must  insist  that  an  exhaustive  analysis  of  a  patient's 
condition  often  will  lead  to  conclusions  less  imponderable  than  his  ex 
parte  statement  would  imply.  The  case  above  outlined  on  the  record 
blank  will  not  only  show  an  example  of  possible  diagnosis,  but,  if 
analyzed,  will  show  also  that  the  cure  of  aggravated  local  lesions  may 
not  result  in  the  complete  recovery  of  the  patient;  such  cure  will, 
however,  be  an  important  step  in  the  right  direction.  A  common 
mistake,  when  there  are  other  more  general  and,  perhaps,  more  serious 
anomalies,  is  to  expect  prompt  and  complete  relief  upon  the  correction 
of  local  lesions.  It  would  also  be  equally  a  mistake  to  follow  the  possible 
imphcation  of  Goodell,  and,  because  we  know  that  local  treatment 


DIAGNOSIS  55 

of  palpable  local  lesions  cannot  completely  cure  the  patient,  fail  to 
give  that  treatment,  and  thereby  fail  to  cure  her  so  far  as  we  can. 

It  is,  moreoNer,  imj)r()l)al)le  that  a  harmless  antefdexioii,  a  trifling 
lencorrha^i,  a  slight  displacement  of  the  womb,  a  small  tear  of  the 
cervix,  an  insignificant  rent  of  the  perineum,  or  an  ovarian  ache  would 
often  lead  a  serious  practitioner  away  from  the  "bottom  factor"  to 
useless  or  injurious  gynecological  treatment. 

Xot  less  essential  than  the  gynecological  part  of  the  record  is  that 
which  belongs  to  the  general  condition  of  the  patient.  Age,  tempera- 
ment, bodily  habit,  heredity,  color,  the  heart  and  blood-vessels,  the 
digestive  tract,  the  liver,  spleen,  and,  even  more  important,  the  kidneys, 
and  close  and  careful  attention. 


THE    PHYSICAL    EXAMINATION 

Examination  calls  into  use  the  special  senses,  supplemented  by  such 
conditions,  instruments,  and  appliances  as  will  increase  the  power  or 
widen  the  range  of  the  senses. 

The  conditions  to  be  fulfilled  for  an  adequate  examination  are  num- 
erous and  variable.  Among  them  are:  1.  Cleanliness.  2.  A  suitable 
table.  3.  Proper  attitude  and  position  for  the  patient,  and'  empty 
bladder  and  rectum. 

Cleanliness  and  Asepsis  have  been  emphasized  in  the  last  chapter; 
their  importance  cannot  be  exaggerated.  Exception:  if  it  is  desired 
to  study  the  character  of  the  uterine,  vaginal,  or  vulvar  secretions, 
the  preliminary  douche  and  disinfection  of  the  parts  may  be  omitted. 

The  Rectum  and  Bladder  should  be  empty  for  the  following  reasons : 
1.  These  viscera,  when  full,  displace  the  pelvic  organs  by  pressure.  2. 
Retained  feces  and  urine  may  be  mistaken  for  solid  and  cystic  tumors. 
The  full  bladder  pushes  the  uterus  and  its  appendages  upward  and 
backward  and  greatly  increases  the  difficulty  of  conjoined  examination. 
Even  a  small  quantity  of  urine  in  the  bladder  may  cause  the  patient 
to  make  the  abdominal  muscles  so  tense  that  the  uterus  cannot  be  felt 
between  the  hand  over  the  pubes  and  the  examining  finger  in  the 
vagina.  A  preliminary  cathartic  to  clear  the  bowels  of  feces  and  gas 
should  therefore  precede  the  first  examination. 

The  Examining  Table. — The  digital  examination  may  be  made  with 
the  patient  lying  on  a  sofa  or  bed;  but,  as  Marion  Sims  has  taught, 
"  the  one  is  too  low  and  the  other  is  too  soft  and  yielding  for  a  speculum 
examination."  Even  the  digital  touch  and  palpation  are  much  better 
made  on  a  table.  If  the  bed  is  used,  the  patient  should  lie  across  it, 
with  the  hips  well  to  the  edge,  and  not  lengthwise  of  the  bed.  The  table 
is  essential  for  a  thorough  speculum  examination.  The  conventional 
office  chair,  although  less  objectionable  than  the  sofa  or  bed,  is,  by 
comparison  with  the  table,  inferior.  An  ordinary  pine  kitchen  table, 
two  feet  wide,  four  feet  long,  and  two-and-one-half  feet  high,  covered 
with  a  blanket  and  sheet  and  supplied  with  a  pillow,  will  answer  every 


56  GENERAL   PRINCIPLES 

purpose  almost  as  well  as  the  more  elaborate  table  commonly  used 
in  office  and  hospital  work.  There  is  some  advantage  in  having  the 
end  of  the  table  upon  which  the  pelvis  rests  about  three  inches  higher 
than  the  end  upon  which  the  head  rests. 

In  making  a  digital  or  conjoined  examination  with  the  patient 
lying  on  the  table,  the  examiner  stands  at  the  foot  of  the  table  facing 
the  patient,  and  passes  the  examining  hands  between  the  knees. 

The  Position  of  the  Patient. — Two  positions  are  in  common  use, 
the  dorsal  and  the  left  lateroprone  position  of  Sims.  The  knee-breast, 
the  standing,  and  the  prone  positions  are  used  less  frequently;  each  has 
advantages  peculiar  to  itself  and  to  the  conditions  under  which  it  is 
employed. 

Examination  of  Young  Girls. — The  first  examination  of  a  young 
girl  should  be  approached  with  reluctance,  and,  if  possible,  avoided. 
The  advantages  of  anaesthesia  from  the  standpoint  of  modesty  must 
be  apparent  to  all.  If  the  hymen  is  intact,  an  eflfort  should  be  made 
to  gain  the  necessary  information  by  a  conjoined  digital  exploration 
through  the  rectum,  the  palpating  hand  being  over  the  hypogastrium. 

Placing  the  Patient  on  the  Table. — The  clothing  about  the  waist 
having  been  loosened,  the  patient  steps  upon  a  chair  which  has  been 
placed  at  the  foot  of  the  table,  and,  the  skirts  having  been  raised 
behind,  sits  upon  the  extreme  end  of  the  table.  She  is  then  assisted 
to  lie  upon  her  back,  the  head,  not  the  shoulders,  being  supported  by 
a  pillow.  Before  lying  down  she  is  covered  with  a  sheet.  Under  the 
sheet,  and  without  exposure,  -the  feet  are  lifted  from  the  chair  to  the 
table  and  placed  six  inches  apart ;  the  clothing  in  front  is  pushed  above 
the  knees  and  the  knees  are  widely  separated.  The  flexure  of  the  thighs, 
secured  by  placing  the  feet  on  the  table,  relaxes  the  abdominal  muscles 
and  facilitates  the  palpation.  The  edge  of  the  sheet  as  it  falls  over  the 
knees  is  parted  back  between  the  thighs  so  as  to  expose  only  the  part 
to  be  inspected — that  is,  the  vulva.  The  patient  is  assured  that  she  is 
neither  to  be  hurt  nor  unduly  exposed.    She  is  now  ready  for : 

1.  Inspection. 

2.  Digital  examination  of  the  vagina  and  rectum. 

3.  Conjoined  examination. 

4.  Percussion,  palpation,  and  auscultation. 

5.  Mensuration. 

6.  Instrumental  examination. 

1.  Inspection 

General  inspection  of  the  whole  patient  is  not  only  essential  for 
careful  general  diagnosis,  but  it  is  also  important  to  inspect  the  external 
genitals  as  a  forewarning  against  possible  inoculation  of  the  examining 
finger  with  venereal  or  other  infection.  Some  historic  cases,  there  are, 
of  surgeons  who  have  gone  to  their  death  from  this  cause.  The  writer 
is  acquainted  with  not  less  than  twenty  physicians  who  have  contracted 
syphilis,    some  of   them  fatal   syphilis,  through  digital   touch.     Any 


DIAGNOSIS  57 

abrasion  on  the  Imnd  should  l)c  |)rotcct('(l  witli  ;i  finucr-fot  or  a 
collodion  and  cotton  drcssin<i':  a  \vr\  thin  la\cr  of  cotton  is  placed 
o\cr  the  al)rasion  l)efore  the  collodion  is  ai)i)lied.  One  should  look  for 
lacerations,  scars,  and  other  exidences  of  parturition,  \ulvitis,  tumors, 
urethral  caruncles,  urethritis,  eruptions,  hemorrhoids,  anal  fissure, 
fistula  in  ano,  ])in\vorms,  eczema,  (X'dema,  cystocele,  rectocele,  ulcers, 
inflanunation  of  Skene's  tjlands,  and  other  anomalies,  and  shoulfl  note 
the  caliper  and  elasticity  of  the  vulvar  orifice.  Is  the  clitoris  enlar<);ed 
or  imprisoned  under  an  adherent  prepuce?  Such  adhesions  may  give 
rise  to  pronounced  reflex  disorders.  If  the  vulva  is  that  of  a  virgin, 
it  is  apt  to  be  small,  with  the  hymen  perforated  only  by  one  or  more 
small  openings.  The  absence  of  such  a  hymen,  however,  is  neither  proof 
nor  even  strong  evidence  of  unchastity.  The  virgin  labia  minora  are 
small,  firm,  double  folds  of  skin.  If  they  are  long,  loose,  and  flabby, 
and  especially  if  the  vulvar  orifice  is  patulous,  the  indications  are  that 
the  woman  has  had  one  or  more  children,  or  has  had  much  treatment, 
or  has  practised  self-abuse,  or  has  been  the  subject  of  some  other 
mechanical  interference. 

Inspection,  however,  is  not  limited  to  the  reproductive  organs  nor 
to  external  parts;  it  may  extend  through  the  aid  of  the  speculum  to 
the  vagina,  the  interior  of  the  bladder,  the  urethra,  the  rectum,  and, 
by  abdominal  section,  to  the  interior  of  the  abdomen  and  pelvis.  The 
surface  of  the  abdomen  is  also  open  to  visual  examination,  and  by  its 
enlargement  and  contour  may  disclose  the  presence  or  character  of  a 
tumor  or  ascitic  accumulation. 

2.  Digital  Examination 

Left-hand  Method. — The  ad\antage  of  the  left  index-finger  for 
digital  touch  in  preference  to  the  right  was  demonstrated  and  its  use 
popularized  by  ^Marion  Sims.  The  great  superiority  of  the  left-hand 
method  is  acknowledged  usually  by  those  who  have  accustomed  them- 
selves to  both.  The  following  are  some  of  the  reasons  for  this  supe- 
riority: 1.  The  tactile  sense  of  the  left  finger  is  educated  more  easily. 
2.  Its  palmar  surface  more  readily  comes  in  close  relations  with  the 
left  side  of  the  pelvis,  and  disease  is  more  frequent  on  the  left  than  on 
the  right  side.  3.  The  stronger  right  hand  is  reserved  for  external 
palpation.  4.  The  right  hand  is  left  free  to  pass  the  probe,  or  sound, 
or  to  manipulate  any  instrument.  One  finger  usually  will  gain  as 
much  information  as  two.  The  introduction  of  two  fingers,  except  in 
a  capacious  vagina,  is  painful.  Two  fingers  may,  however,  sometimes 
be  of  use  in  the  examination  of  tumors. 

Lightness  of  Touch. — The  manner  of  digital  touch  has  been  well 
described  by  Emmet  as  follows:  "When  the  sense  of  touch  has  been 
cultivated,  it  yields  more  information  upon  which  to  base  a  diagnosis 
than  can  be  gained  by  the  eye  alone,  even  when  used  under  equally 
favorable  circumstances.  Therefore  the  digital  examination  shoidd 
always  be  thoroughly  and  systematically  made.     It  is  all-essential  to 


58 


GENERAL   PRINCIPLES 


possess  a  knowledge  of  departures  from  a  healthy  condition.  The 
lighter  the  touch  the  more  acute  it  will  be,  and  the  more  clearly  will 
it  appreciate  slight  changes.  It  is,  indeed,  remarkable  how  individuals 
vary  in  their  method  of  making  examinations.  One  will  proceed  with 
as  much  vigor  as  if  he  were  boring  a  hole,  and  finds  little  more  than 
the  cervix,  which  feels  like  an  obstruction  in  his  way.  He  gains  no 
information  of  importance,  and  inflicts  unnecessary  pain.  Another 
will  pass  his  finger  lightly  over  every  portion  of  the  vagina,  and,  without 
ha^ang  caused  any  pain,  quickly  ascertain  enough  to  enable  him  fully 
to  understand  the  case." 

FiorRE  10 


Digital  eversion  of  the  anus. 


Distention  of  the  Bladder  during  Examination.— In  the  chapter  on 
Displacements  of  the  Uterus  stress  is  laid  on  the  great  iniportance  of 
having  the  bladder  and  rectum  empty  when  digital  examinations  are 
being  made.    The  author's  experience  has  shown  that  when  palpation 


-DIAGNOSIS  59 

of  the  ovaries  is  desired,  the\'  sometimes  are  forced  down  within 
reach  of  digital  tonch  with  starthnt;:  distinctness  when  tlie  bhidder 
is  distended  with  fluid.  The  recjuired  distension  may  i)e  secured  by 
throwing  in  sterile  salt  water  1  per  cent,  through  a  catheter  attached 
to  a  fountain  syrino-e. 

Conduct  of  Digital  Examination. — The  hand  ha\in<,^  been  washed 
carefully,  the  left  index-finger  is  lubricated  with  glycerin,  mild  castile 
soap,  or  glycerin  emollient  (Chapter  11.),  and  then  slowly  introduced, 
the  palmar  surface  being  directed  downward  so  as  to  depress  the  peri- 
neum toward  the  rectum;  it  notes  the  rigidity  of  the  ])erineum,  the 
presence,  absence,  or  consistence  of  the  feces  in  the  rectum,  the  caliber 
and  relaxation  or  rigidity  of  the  vagina,  and  the  condition  of  the  sacrum 
and  coccyx.  The  palmar  surface  of  the  finger  now  is  directed  alternately 
toward  the  lateral  and  the  anterior  portions  of  the  pelvis  and  swept 
aroimd  the  cervix.  The  direction,  size,  form,  and  consistence  of  the 
cervix,  the  caliber  and  form  of  the  os  externum,  and  the  presence  or 
absence  of  laceration  become  apparent.  The  right  hand  now  is  placed 
over  the  abdomen  behind  the  pubes,  and  the  inquiry  continued  by 
conjoined  examination.  Irritation  of  the  clitoris  may  give  rise  to  sexual 
excitement;  hence  the  examining  hand  should  be  kept  well  away  from  it. 

Digital  examination  with  the  patient  standing  has  some  value  as  a 
means  of  diagnosis  in  uterine  displacements.  The  examination  may  be 
made  with  the  woman  in  the  left  lateroprone  position,  but  this  posi- 
tion is  reserved  rather  for  speculum  examinations  and  operations. 

E version  of  the  Anus,  as  shown  in  Figure  10,  enables  the  examiner 
to  judge  of  the  condition  of  the  lower  part  of  the  rectum  and  anus 
and  may  be  done  either  in  the  dorsal  or  lateral  position. 

3.  Conjoined  Examination 

Conjoined  Vaginal  Examination,  often  called  bimanual  palpation, 
is  designed  to  bring  within  the  range  of  touch  all  the  pelvic  organs. 
These  organs,  one  by  one,  in  some  cases  are  lifted  forward,  by  the 
finger  or  fingers  in  the  vagina,  toward  the  anterior  abdominal  wall, 
where  they  can  be  palpated  by  the  right  hand  pressed  down  behind 
the  pubes.  Usually,  however,  the  right  hand  forces  them  down  to  a 
point  where  they  may  be  examined  readily  by  digital  touch.  The 
latter  method  is  usually  preferable,  because  the  application  of  much 
force  in  the  vaginal  or  rectal  touch  may  be  harmful  to  the  patient 
or  may  impair  the  tactile  sense  of  the  finger.  A  combination  of  both 
methods  is  desirable.  The  necessary  amount  of  force  will  vary  with 
the  tolerance  of  the  patient  and  the  skill  of  the  examiner.  The  reach 
of  the  examining  finger  is  increased  materially  by  forcing  the  elastic 
perineum  backward  toward  the  interior  of  the  pelvis. 

Bimanual  examination,  to  be  effective,  requires  long  practice.  The 
beginner  is,  first,  to  bring  the  organs  properly  between  the  two  hands; 
second,  to  appreciate  what  may  be  within  his  reach.  Should  the 
thickness  or  rigidity  of  the  abdominal  walls  prevent  the  downward 


60 


GENERAL  PRINCIPLES 


pressure  of  the  hand  behmd  the  piibes,  the  resistance  may  be  overcome 
by  continuous  firm  pressure,  or  by  successive  short  strokes  of  vibra- 
tory massage,  or  by  circular  massage.  The  diflSculty  is  often  the  result 
of  the  patient's  nervousness.  The  examiner  should,  therefore,  avoid 
sudden  movements  in  manipulation.    A  deep  inspiration  b}^  the  patient, 


Figure  1 1 


Conjoined  vaginal  examination. 


followed  by  a  quick  expiration,  while  steady  pressure  is  being  made, 
may  momentarily  relax  the  muscles,  and  thereby  afford  the  examiner 
an  opportunity  of  rapidly  palpating  the  pelvic  organs.  An  examiner 
of  acute  touch  and  quick  perception  will  gain  sometimes  instantaneously 
the  required  information  in  this  way.  During  the  examination  the 
patient  should  keep  the  mouth  open. 


DIACXOSIS 


61 


It"  the  uterus  and  its  ai)i)endage.s  are  sensitixe,  or  fixed  1)\"  adliesions, 
the  attenij>t  to  foree  them  up  toward  the  outside  hand  may  he  futile  or 
even  (hin<ier()us.  Deep  pali)ation  l)?liind  the  puhes  is  then  necessary. 
One  should  remember,  however,  that  even  a  httle  force  injudiciously 
applied  by  either  hand  may  rui)ture  a  pus-pocket  or  tube,  and  thereby 
lead  to  serious  results. 


Rectal  touch,  conjoined  examination.  In  examining  at  the  patient's  house  n-ithout  remo\-ing  the 
coat  or  loosening  the  starched  shirt-cuffs,  the  examiner  may  push  them  up  over  the  wrists  and  retain 
them  there  by  pulling  down  the  sleeves  of  the  undershirt,  and  turning  them  back  over  the  cuffs,  as 
shown  in  this  illustration. 


Bimanual  palpation  enables  one  to  judge  of  the  following  condi- 
tions: the  size,  form,  location,  position,  consistence,  and  mobility  of 
the  uterus,  the  presence  or  absence  of  a  pelvic  tumor.  If  the  uterus  is 
displaced,  is  it  replaceable,  or  i.>  it  l)ound  by  adhesions,  and  therefore 


62 


GENERAL   PRINCIPLES 


irreplaceable?  If  there  is  a  tumor  in  the  pelvis,  is  it  a  neoplasm 
or  an  inflammatory  swelling?  If  the  former,  it  is  not  sensitive;  if 
the  latter,  it  is  tender  on  pressure.  Is  it  connected  with  the  uterus, 
or  the  Fallopian  tube,  or  the  broad  ligament,  or  the  ovary?  Is  it 
cystic  or  solid,  malignant  or  benign?  Does  it  originate  in  the  pelvis, 
or  in  the- abdominal  cavity,  and  above  all,  is  it  possibly  due  to  preg- 
nancy? These  questions  will  come  up  again  under  the  diagnosis  of 
special  disorders. 


FiGUHE    13 


Conjoined  rectovaginal  palpation. 

Conjoined  Rectal  Examination. — Conjoined  examination  by  rectal 
instead  of  vaginal  touch  may  confirm,  disprove,  or  supplement  the 
previous  observations  and  impressions.  F'igure  12.  Rectal  touch, 
whether  digital  or  conjoined,  may  be  impeded  by  coils  of  intestine  in 
the  pelvis  interposed  between  the  finger  and  the  viscera  to  be  palpated. 
This  may  be  avoided  by  a  simple  device  of  Kelly's:  "The  rectum  and 
bladder  are  first  evacuated,  the  patient  is  put  in  the  knee-chest  posture, 


DIAGNOSIS 


63 


and  a  speculum  is  introduced  into  the  rectum.  This  lets  in  a  large 
amount  of  air,  and  the  howel  balloons  out  and  applies  itself  broadly 
over  the  sacral  hollow  and  the  posterior  surfaces  of  the  uterus  and 
left  broad  lii^ament,  and  in  a  minute  or  two  the  small  intestine  falls 
away  into  the  upper  abdomen.  The  patient  must  then  be  turned  on 
her  back,  care  being  taken  to  keep  the  pelvis  constantly  higher  than 
the  rest  of  the  abdomen,  so  as  not  to  let  the  intestines  gra\itate  again 
into   the  pelvic   cavity.     On   making   the   bimanual   examination   the 


Fkjckl   14 


Uterus  drawn  down  by  lueaiis  of  tooth-forceps  to  facilitate  manual  examination  or  replacement: 
a,  rubber  finger-cot  on  finger;  b,  rubber  finger-cot  rolled  up. 


pelvic  viscera  are  felt  with  startling  distinctness,  the  rectal  finger 
enters  a  large  air-cavity  no  longer  impeded  by  the  mucous  folds;  the 
opening  from  the  lower  into  the  upper  rectum  is  readily  found;  and 
the  posterior  surface  of  the  uterus  and  the  ovaries  and  tubes  feel  as  if 
skeletonized  in  the  pelvis.  They  lie  so  clearly  exposed  to  touch  that 
their  minuter  surface  peculiarities,  fissures  and  elevations  and  varia- 
tions in  consistence  can  be  detected."  This  peculiar  ballooning  of  the 
rectum  is  observed  often  in  obstruction  and  paresis  of  the  bowel,  and 


64 


GENERAL  PRINCIPLES 


may  be  felt  with  the  patient  in  the  dorsal  position  without  recourse  to 
the  device  of  Kelly. 

Conjoined  Rectovaginal  Examination  is  made  with  the  left  index- 
finger  in  the  rectum,  the  thumb  in  the  vagina,  and  the  right  hand 
behind  the  pubes.  See  Figure  13.  In  this  M^ay  the  perineum  is  pushed 
w^ell  up  toward  the  interior  of  the  pelvis.  If  the  abdominal  wall  is 
thin  and  relaxed,  the  various  pelvic  organs,  when  forced  down  by  the 
hand  behind  the  pubes,  may  be  picked  up,  so  to  speak,  between  the 
thumb  and  finger  and  definitely  palpated. 


Figure  15 


Palpation  of  the  roots  of  the  sciatic  nerve  by  rectal  touch. 


Traction  as  an  Aid  to  Conjoined  Examination. — Palpation  of  the 
pelvic  organs,  especially  the  ovaries  and  Fallopian  tubes,  is  facih- 
tated  often  by  drawing  the  uterus  toward  the  vulva  by  means  of  a 
uterine  tenaculum  or  small  tooth-forceps.  Figure  14.  During  the 
palpation  these  instruments  may,  if  necessary,  be  held  by  an  assistant. 

Anaesthesia. — Failure  to  engage  the  uterus  between  the  hands  in 
conjoined  examination  may  be  due  to  fixed  retroversion  or  to  rigidity 
of  the  abdominal  muscles,  or  to  sensitiveness  of  the  parts  under  exami- 
nation, or  to  the  nervousness  of  the  patient.      Intelligent  treatment 


DIAGNOSIS 


65 


may  he  impossible  iiiiiirr  these  eoiKhtioiis  without  anaesthesia.  The 
aeeurate  and  adecjiiate  (hagnosis  thus  ohtaiued  k'sseus  the  iium})er 
of  exph)ratory  ineisions  and  umieeessary  operations,  prevents  a  vast 
amount  of  indefinite  injurious  h)eal  treatment,  and  substitutes  rational 
medicine  and  snruiTy. 

The  Roots  of  the  Sciatic  Nerve  may  be  palpated  through  the  rectum, 
as  shown  in  Figure  15.  Such  an  examination  sometimes  will  reveal 
the  source  of  obscure  pelvic  pain  which  has  previously  been  attributed 
to  ovarian  or  uterine  origin.  The  patient  must  be  examined  without 
antvsthesia,  and  as  the  fingers  are  drawn  over  the  tender  cord  a  cry 
of  pain  will  be  elicited. 

Figure   1G 


A.   Myoma  in  the  posterior  wall  of  the  uterus. 


B.   Retroflexion  of  the  uterus. 


Conjoined  Examination  with  the  Sound. — One  may  be  unable  by 
touch  to  decide  whether  a  tumor  is  of  uterine  or  extra-uterine  origin. 
The  uterus  may  then  be  immobilized  by  the  sound  passed  into  the 
uterine  canal  and  held  immovable  by  the  hand  of  an  assistant,  or  the 
uterus  may  be  steadied  by  a  tooth-forceps  or  tenaculum  attached 
to  the  cervix.  The  examiner  then  may  determine  whether  the  tumor 
moves  with  the  uterus  or  independently  of  it.  In  case  of  a  uterine 
tumor  with  a  long  pedicle,  or  of  an  extra-uterine  tumor  adherent  to  the 
uterus,  the  test  may  fail. 

The  necessity  of  conjoined  examination  is  apparent  in  Figures  16 
and  18.  Vaginal  touch  alone  in  Figure  16,  A,  which  represents  a 
5 


66 


GENERAL   FRIhX'IPLES 


myomatous  uterus,  ^\■()ul(l  i>■i^'e  the  same  impression  as  in  Figure  16, 
B,  which  shows  a  retroflexed  uterus.  Coujoined  examination  in  Figure 
16,  A  and  B,  would  estal)lish  the  fact  of  myoma  in  one  case  and  the 
retroflexion  in  the  other.  The  exact  direction  of  the  uterine  canal 
and  the  relations  of  the  uterus  to  the  tumor  might  in  such  cases  be 
learned  by  passing  the  probe  or  the  sound. 

Figure   17 


Conjoined  examination  of  a  solid  tumor  of  the  uterus.     Here  the  tumor-mass  is  palpabl\-  a  part 

of  the  uterus. 


4.  Percussion,   Palpation,   and  Auscultation 

These  means  of  diagnosis  are  applicable  to  the  differentiation  of 
abdominal  tumors  and  enlargements  of  inflammatory  origin,  especially 
pregnancy.  The  inquiry  should  include  both  gynecological  disorders 
and  others  that  simulate  or  complicate  them.  Among  the  latter  may 
especially  be  mentioned  appendicitis,  a  condition  frequently  associated 
with  infection  of  the  uterine  appendages,  particularly  on  the  right 
side.  .  One  who  has  not  systemically  included  the  renal  organs  in  his 
examination  will  be  astounded  at  the  revelations  of  such  investigations. 
Hydronephrosis,  abscess  and  stone  in  the  kidney,  tuberculous  kidney, 
loose  and  floating  kidney,  and  stricture  of  the  ureter  are  among  the 


D/Acxosis  (;7 

j);itlit)l()iiic;il  coiiditioiis  coiiiiiioiily  oxcrlookcd.  Tlic  nicn-  iiiciitioii  of 
iiitfstiiial,  jj:astri(',  splt'iiic.  and  lu'])atic  disorders  should  he  sufficient. 
Relaxation  of  the  alxiominal  walls,  with  eonseciuent  falling'  of  the 
intestines — enteroptosis — associated  also  with  the  falling  of  other  ab- 
dominal ()r<;ans,  especially  the  stomach  and  kidney  is  a  fretjuent,  and 
unreco.unii/ed  cause  of  abdominal  and  peKic  disorders.  See  Pendulous 
Abdomen  and  Displacement  of  Ai)d()niinal  \'iscera,  at  the  close  of  the 
chapter  on  MaiJocations  of  the  I'tcrus. 


Conjoined  examination  of  a  cystic  tumor  of  the  ovarj'-  The  hands  of  an  assistant  are  mo\-inp  the 
tumor  from  side  to  side.  The  uterus  does  not  move  with  the  cyst.  The  hands  of  the  examiner  are 
separating  the  cyst  from  the  uterus.  The  separation  of  the  cyst  from  the  uterus  and  the  independent 
movement  of  it  demonstrate  it  to  be  of  extra-uterine  origin. 


5.  Mensuration 

^lensuration  is  important  in  the  examination  of  new  growths  and 
other  lesions  causing  abdominal  enlargement,  and  will  be  considered 
further  in  connection  with  the  special  diagnosis  of  these  disorders. 
The  mea.surements  of  the  bony  pelvis  frequently  have  great  signifi- 
cance, not  only  from  the  obstetrical,  but  also,  especially  in  the  matter 


68  GENERAL   PRINCIPLES 

of  displacements  and  malformations,  from  the  gynecological  point  of 
view.  The  reader  is  referred  for  pelvic  mensuration  to  the  literature 
of  obstetrics. 

G.  Instrumental  Examinations 

As  already  stated,  the  development  of  modern  gynecology  has  been 
made  possible  by  the  use  of  instruments  of  precision  designed  to  in- 
crease the  power  or  widen  the  range  of  the  senses.  The  diagnostic 
methods  already  described  usually  will  furnish  the  groundwork  for 
diagnosis.  Instrumental  examination  may  supplement  and  verify  con- 
clusions already  foreshadowed.  Some  of  the  instruments  used  for 
diagnostic  purposes  are: 

1.  The  speculum.  5.  The  exploratory  needle  and  aspirator. 

2.  The  sound  and  probe.      G.  The  stethoscope. 

3.  The  dilator.  7.  The  microscopic. 

4.  The  curette.  8.  The  urethroscope  and  cystoscopy 
The  Speculum. — The  choice  of  the  speculum  is  simplified  by  the 

statement  that  of  the  innumerable  varieties  only  two  require  serious  con- 
sideration, and  that  these  two  act  on  the  same  principle — as  perineal 
retractors.    They  are: 
Sims'  speculum. 
Simon's  speculum. 

Sims'  Speculum  is  an  instrument  of  great  simplicity  and  effectiveness. 
The  objection,  sometimes  urged,  that  the  efficient  use  of  it  requires 
long  practice,  is  a  mistake.  Whoever  once  masters  the  simple  prin- 
ciples of  the  left  lateroprone  position  will  have  little  or  no  difficulty. 
The  failure  to  appreciate  the  mechanical  relations  of  this  position 
to  Sims'  speculum  will  explain  most  of  the  disappointments  resulting 
from  its  use.  Another  alleged  disadvantage  of  Sims'  speculum  is 
the  necessity  of  a  trained  assistant  to  hold  it.  If  the  examiner  himself 
knows  how  the  instrument  should  be  held,  the  assistant  need  not  be 
trained.  In  gynecological  examinations  the  presence  of  a  third  person 
is,  for  obvious  reasons,  an  advantage.  Examinations  at  the  patient's 
house  may  be  made  usually  with  the  assistance  of  some  member  of  the 
family.  The  physician  who  has  a  large  office  practice  should  have 
the  assistance  of  an  office  attendant;  or  if  this  is  impracticable,  a 
modified  self-retaining  Sims'  speculum  may  be  used. 

Thomas,  after  long  experience  with  other  instruments,  makes  a 
statement  something  like  this:  "Learn  the  use  of  Sims'  speculum, 
persevere  in  the  method  for  three  months,  and  you  will  never  give  it 
up."  Emmet,  whose  experience  with  the  instrument  is,  perhaps, 
greater  than  that  of  any  other,  says:  "This  instrument  is  so  simple 
in  design,  and  so  perfectly  does  it  fulfil  every  requirement,  that  it  will 
probably  never  be  superseded. 

The  Self -retaining  Sims'  Speculum. — Modifications  of  Sims'  speculum 
to  make  it  self-retaining  have  been  devised  by  Emmet,  Cleveland, 
and  others.  They  are  aU  inferior  to  the  original  Sims'  instrument, 
but  superior  to  the  multiform  cylindrical  and  bivalve  instruments. 


DIAGNOSIS 


()9 


Figure  19 


Percussion  in  the  diagnosis  of  abdominal  enlargement  due  to  accumulation  of  ascitic  fluid.  Intes- 
tines float  to  the  surface  of  the  fluid.  Resonance  over  intestines.  Dulness  in  flanks  below  level  of 
fluid.  Change  in  position  of  the  patient  would  make  corresponding  change  in  areas  of  resonance  and 
dulness — that  is.  the  higher  parts  would  give  resonance  and  the  lower  parts  didness. 


FiorRE  20 


Incorrect  representation  of  Sims'  left  lateroprone  position,  taken  from  a  standard  text-book. 


70 


GENERAL  PRINCIPLES 


Cleveland's  self-retaining  speculum  is  one  of  the  best  examples  of  its 
kind. 

The  Left  Lateroprone  Position. — In  order  to  appreciate  the 
action  of  Sims'  speculum  it  becomes  necessary  to  study  the  effect  of 
Sims'  lateroprone  position  upon  the  pelvic  organs.  Like  the  knee- 
breast  position,  of  which  it  is  a  modification,  it  causes  the  vagina  to  fill 
with  air,  and  the  anterior  and  posterior  vaginal  walls — or,  to  speak 
more  comprehensively,  the  pubic  and  sacral  segments  of  the  pelvic 
floor — to  separate.  The  speculum  then  exaggerates  the  effect  of  this 
position  by  hooking  or  drawing  back  the  perineum,  which  exposes  almost 
the  entire  surface  of  the  widely  opened  vagina,  and  causes  the  cervix 
to  be  drawn  somewhat  toward  the  vulva. 

Figure  21 


Correct  lateroprone  position.    The  reader  is  urged  to  study  this  Figure  in  connection  with  the  text. 


Two  requirements  are  essential  to  the  successful  use  of  Sims'  spec- 
ulum— correct  position  of  the  patient  and  proper  holding  of  the  in- 
strument. The  patient  is  to  be  placed  on  the  left  side,  the  hips  being 
over  the  left-hand  corner  of  that  end  of  the  table  which  is  toward  the 
operator;  the  knees  are  to  be  drawn  up  toward  the  abdomen,  and  the 
right  thigh  flexed  slightly  more  than  the  left.  The  patient's  left  arm 
rests  behind  her  on  the  table.  This  permits  the  right  shoulder  to  be 
thrown  forward  and  depressed  toward  the  right  side  of  the  table,  so 
that  the  position  becomes  lateroprone — that  is,  lateral  and  slightly 


DiAdxnsis 


prone  at  tlu'  hips,  and  almost  wliolly  |)ron('  at  (lie  shoulders.  'V\\c  left 
side  of  the  head  r(>sts  ui)on  the  table,  the  face  looking  to  thi'  ri^ht.  The 
riijht  arm  hani^s  o\xt  the  ri^ht  side  of  the  table,  and  the  lon<i;  axis  of 
the  trnnk  extends  ()l)li(iuely  across  the  table  from  the  left  to  right. 


.Sims'  speculum  and  depressor  in  use:  n,  depressor;  h,  specidum;  r,  Eminrt's  dressing-forceps;  d, 
Emmet's  uterine  tenaculum.  The  upper  hand  shows  the  position  of  the  examiner's  finfrers  in  the 
introduction  of  tlie  speodum.  Tliese  instruments  are  in  general  use  for  examination  l■),^•  the  Sims 
metliod.      Two  or  ninre  uterine  tenacula  are  required. 


The  steps  of  an  examination  with  Sims'  speculum  are  these: 

1.  Place  the  patieut,  the  waist  clothing  being  loose,  in  Sims'  left 

lateroprone  position,  the  head,  not  the  shoulders,  supported  by  a  very 

thill  pillow. 


72 


GENERAL  PRINCIPLES 


2.  Protect  the  buttocks  with  the  towels. 

3.  Let  the  nurse  hft  up  the  right  labium. 

4.  Introduce  one  blade  of  the  speculum  and  place  the  other  in  the 
nurse's  hand. 


Figure  23 


Examination  with  Sims'  speculum.  The  towels  ordinarily  used  to  cover  parts  around  the  vulva 
are  omitted  in  order  to  show  the  exact  position  of  the  pelvis  and  thighs.  Passage  of  probe  or  curette; 
cervix  steadied  by  vulsellum. 


5.  With  the  depressor  in  the  right  hand,  push  the  anterior  vaginal 
wall  forward  until  the  cervix  uteri  comes  into  full  view. 

6.  With  a  wad  of  absorbent  cotton  in  the  grasp  of  the  uterine  dress- 
ing-forceps, wipe  out  any  secretion  in  the  vagina  that  may  be  found. 

7.  If  the  sound  is  to  be  passed  or  the  uterus  otherwise  instrumen- 
tally  examined,  change  of  depressor  to  the  left  hand  and  use  the  right 


DIAGNOSIS 


73 


for  this  purpose.  Instead  of  usinji;  the  depressor  during  the  instru- 
mentation of  the  uterus,  it  is  often  desirable  to  steady  the  cervix  with 
the  tenac'uhnn  or  tenacuhnn  forceps.     Figure  24. 


Uteras  exposed  by  Simon's  speculum.  Dorsal  position.  Cer\-ix  uteri  steadied  by  tenaculum. 
L'terine  canal  beinj:  measured  by  Peaslee's  sound:  a.  uterine  tenaculurn;  b,  Peaslee's  sound;  c.  silver 
probe:  d,  Simon's  speculum  are  reduced  to  about  one-half  the  ordinary  size. 


In  many  cases  the  vagina  balloons  with  the  inrush  of  air,  and  the 
w^hole  field  comes  into  full  view  without  the  use  of  the  depressor. 


74 


GENERAL   PRINCIPLES 


The  patient  is  now  ready  for:  (1)  inspection  of  the  entire  vaginal 
surface;   (2)  instrumental  examination  of  the  interior  of  the  uterus. 

Vaginitis,  ulcers,  laceration  of  the  cervix,  erosion,  cystic  degenera- 
tion, vaginal  cicatrices,  traumatisms,  vaginal  fistulse,  carcinoma  of 
the  cervix,  and  other  new  growths  if  present  may  now  be  observed. 
Pathological  discharges  may  be  taken  for  microscopical  examination, 
and  their  source,  whether  from  the  uterus  or  the  vagina,  may  be  observed 

Simon's  Speculum,  shown  in  Figure  24,  is  a  perineal  retractor  similar 
to  Sims',  but  with  shorter  and  flatter  blades,  which  are  made  of  dif- 
ferent shapes  and  sizes.  It  differs  from  Sims'  chiefly  in  the  manner 
of  use,  which  requires  the  patient  to  be  on  the  back,  and  the  thighs 
to  be  flexed  in  the  lithotomy  position.  An  objection  to  this  instru- 
ment is  that  the  vesicovaginal  walls  are  hable  to  fall  toward  the  speculum 
and  the  lateral  walls  fall  together  in  such  a  way  as  to  obscure  the 


Figure  25 


Sounds  of  Simpson  and  Sims  compared-  sections  of  full  size.     The  upper  sound  is  Sims'; 
the  lower  Simpson's. 

field  of  operation.  To  obviate  this  difficulty  one  may  use  a  smaller 
though  similar  retractor  which  acts  in  the  opposite  direction,  like 
the  anterior  blade  of  the  bivalve  speculum,  and,  if  necessary,  lateral 
depressors  on  either  side.  All  of  these  instruments  are  more  or  less 
in  the  operator's  way;  besides,  the  introduction  of  the  sound,  curette,  or 
other  instruments  to  the  interior  of  the  uterus  is  more  difficult  in  the 
dorsal  than  in  the  Sims'  position;  moreover,  if  the  organ  is  anteverted 
or  anteflexed,  the  instrument  is  especially  liable  to  be  arrested  at  some 
point  on  the  posterior  wall  of  the  cervix  or  at  the  internal  os,  and 
refuse  to  pass  further.  Simon's  speculum  is  held  less  easily,  and  requires 
more  assistants,  more  attachments  and  depressors,  than  Sims';  it  gives 
less  light  and  space,  and  for  general  diagnostic  and  surgical  use,  there- 
fore, should  seldom  have  the  preference  over  the  Sims  instrument. 
On  the  other  hand,  the  Simon  instrument  is  preferable  for  vaginal 
hysterectomy  and  many  other  operations  involving  vaginal  section. 


DIAGXO.'^IS  75 

The  Probe  and  Sound  haw  \)vcn  meiitioiu-d  in  conuectioii  w  itii  con- 
joined palpation  as  a  means  of  (lia^jnosis  in  tumors.  In  some  cases 
the  sound,  and  especially  the  probe,  may  he  difficult  or  impossible  to 
l)ass  in  the  dorsal  position,  but  may  readily  be  passed  with  the  aid  of 
Sims'  speculum  in  the  lateral  position. 

To  Pass  the  Probe  or  Sound,  the  Patient  being  in  the  J)in:s-al  Posi- 
tion, without  a  s]jeculum,  first  introduce  the  left  index-fin<jer  to  the  os 
externum,  then,  on  the  fin<,'er  as  a  fjuide,  introduce  the  instrument  into 
the  OS  and  let  it  find  its  own  way,  judiciously  aided  by  slij^ht  force 
to  the  fundus. 

To  Pass  the  Sound  or  Probe  through  the  Speculum,  first  brin<j  the 
cervix  into  view,  seize  it  with  a  uterine  tenaculum  or  A\ith  a  small  vul- 
sellum  forceps,  gently  draw  it  toward  the  vulva,  and  pass  the  instru- 
ment, having  bent  it  before  introduction  to  conform,  as  nearly  as  the 
surgeon  can  judge,  to  the  direction  of  the  canal.  The  forward  trac- 
tion of  the  uterus  greatly  facilitates  the  passage — in  fact,  is  sometimes 
essential. 


Passing  sound;  first  step:    patient  in  dorsal  position  without  speculum:  point  of  sound  is  guided  along 

palmar  surface  of  left  index-finger  to  os  externum. 

Dangers  of  the  Sound  and  Probe. — Numerous  cases  of  grave  infec- 
tion following  the  use  of  these  instruments  have  given  rise  to  an  im- 
pression that  they  are  dangerous.  The  risk,  however,  is  practically 
nothing  if  complete  asepsis  is  maintained.  Even  a  clean  instrument 
may  carry  infection  from  the  vagina  or  vulva:  hence  the  necessity  of 
thorough  asepsis  of  these  parts.  The  sound  without  asepsis  is  more 
objectionable  than  the  probe,  for  it  is  not  only  equally  liable  to  be  the 
carrier  of  sepsis,  but  is  more  liable  to  wound  the  sensitive  endome- 


76  GENERAL   PRINCIPLES 

triiim,  and  thereby  open  the  door  to  microbic  invasion.  The  passage 
of  the  fine  probe  is  usually  painless.  The  sound  in  a  sensitive,  inflamed 
uterus  may  be  intolerable.  Not  the  least  danger  is  that  of  perforation 
of  the  uterine  wall,  especially  in  septic  abortion  and  in  attempted  re- 
placement (prohibited)  of  the  displaced  uterus. 

The  diagnostic  value  of  the  sound  and  probe  is  sometimes  very 
great.  One  may,  for  example,  be  unable  to  locate  the  uterus  except 
by  the  direction  which  the  sound  takes.  The  tortuosity  of  the  canal 
may  at  once  show  the  relations  of  a  myoma  to  the  uterus.  The 
sensations  imparted  to  the  hand  from  the  point  of  the  sound  will 
sometimes  give  evidence  of  pathological  conditions  inside  the  uterus. 
The  length  of  the  canal  in  a  myomatous  uterus  is  increased,  but  not 
materially,  by  the  presence  of  ovarian  and  other  extra-uterine 
tumors.  The  case,  however,  is  rather  exceptional  in  which  the  sound 
or  probe  is  a  necessary  means  of  diagnosis.  The  more  experience  one 
has,  the  more  educated  one's  touch,  the  less  one  will  need  to  use  these 
instruments  for  diagnostic  purposes. 

FiGrEE  27 


Passing  sound:  second  step:     patient  in  dorsal  position  without  speculum.     As  sound  passes  from  OS 
externum  to  fundus  index-finger  is  moved  from  os  externum  to  posterior  vaginal  fornix. 

Uterine  Dilatation  may  be  accomplished  in  the  following  ways: 

1.  By  graduated  bougies  or  sounds  after  the    method  of  dilatation 
of  the  male  urethra. 

2.  By  instruments  of  diverging  blades  constructed  on  the  principle 
of  the  glove-stretcher. 

3.  By  water  dilators. 

4.  By  tents. 

The  object  of  diagnostic  dilatation  is  to  open  the  endometrium  in 
order  that  by  means  of  the  curette  a  specimen  may  be  removed  for 


DiAdxnsis  77 

microscopical  examination,  or  in  order  that  tlie  fin<^er  may  he  used  for 
intra-nterine  di<,Mtal  touch.  Dilatation  is  required  more  frequently 
for  therai)eutic  than  for  diaijnostic  purposes.  The  technique  is  the 
same  for  diaiiiiostic  as  for  therapeutic  dilatation.  See,  therefore,  a 
description  of  the  latter  in  Ciiapter  \'.,  on  Minor  Operations. 

Diagnostic  Curettage. — The  object  of  diagnostic  curettage  is  to 
remove  enough  diseased  tissue  for  microscopical  or  other  examination. 
If  the  curette  is  small,  and  the  os  patulous,  curettage  is  sometimes 
possible  without  aniesthesia  or  previous  dilatation.  Usually,  however, 
the  procedure  requires  both.  Microscopical  examination  of  the  scrap- 
ings is  frequently  the  only  means  of  differentiation  between  hemor- 
rhagic endometritis,  the  remains  of  abortion,  post-abortum  endome- 
tritis, carcinoma,  and  sarcoma.  The  technique  of  curettage  is  described 
in  Chapter  V. 

The  Exploratory  Needle  and  Aspirator  have  the  same  diagnostic 
and  therapeutic  significance  in  gynecology  as  in  other  departments  of 
surgery — i.  e.,  the  removal  of  fluid.  The  contents,  for  example,  of  a 
sactosalpinx,  a  renal  cyst,  a  pelvic  abscess,  or  an  ovarian  cyst  may  be 
removed  for  visual,  chemical,  or  microscopical  examination. 

The  uses  of  the  stethoscope  and  microscope  will,  as  the  occasion 
requires,  be  mentioned  in  the  diagnosis  of  special  diseases. 

Examination  of  the  Anus  and  Rectum 

Rectal  touch  and  eversion  of  the  anus  by  means  of  the  finger  in 
the  vagina  have  been  mentioned  in  the  earlier  pages  of  this  chapter. 
Numerous  specula  have  been  devised  for  inspection  of  the  interior 
of  the  rectum.  For  examination  of  the  lower  part  of  the  rectum, 
Sims'  speculum  is  immeasurably  superior  to  all  others.  It  is  used 
for  this  purpose  the  same  as  for  vaginal  examination — i.  e.,  with  the 
patient  in  the  left  lateroprone  position.     Figure  28, 

The  Proctoscope  and  Sigmoidoscope. — The  frequent  association  or 
confusion  of  rectal  disease  with  the  diseases  of  women  may  render 
necessary  the  inspection  of  the  upper  part  of  the  rectum;  for  this 
purpose  Kelly  uses  a  tubular  speculum,  called  a  proctoscope,  about 
1  inch  in  diameter  and  8  inches  long.  For  still  higher  examinations 
he  uses  the  sigmoidoscope,  of  the  same  diameter,  but  14  inches  long. 
The  patient  is  examined  in  the  knee-breast  position,  and  the  light  is 
thrown  in  by  a  head-mirror.  Examination  through  these  instruments 
is  most  satisfactory. 

Examination   of  the  Urinary  Organs 

The  means  of  examination  are  these: 

1.  Urinalysis. 

2.  Inspection,  palpation,  and  percussion. 

3.  Urethroscopy. 

4.  Cystoscopy  and  ureteral  exploration  and  catheterization. 


78 


GENERAL   PRINCIPLES 


1.  Urinalysis. — The    study    of   tlie    urine    involves^    first,    chemical 
examination;  second,  microscopical  examination. 


Figure  28 


Proctoscopy:  protoscope  S  inches  long  and  1  inch  -n-ide.  The  sigmoidoscope  is  the  same  except 
in  length,  which  is  14  inches.  The  instrument  is  provided  with  an  obturator  (shown  detached  in  the 
lower  part  of  the  Figure) :  it  is  in  nearly  all  respects  except  size  identical  with  the  cylindrical  cystoscope. 
This  instrument  is  supplemented  to  great  advantage  by  the  addition  of  a  small  electric  bulb  so 
situated  in  the  distal  end  of  the  cylinder  as  to  illuminate  directly  the  field  of  examination,  thereby 
doing  awaj^  with  the  reflector. 


The  chemical  examination  will  show  changes  in  the  proportion  or 
quality  of  solids,  and  will  suggest  the  possible  relation  of  these  changes 
to  pathological   conditions   and   functional   disorders.     For  example. 


DIACXOSIS  7!  I 

(Ifcrcasc  in  urra  may  siunily  ii('|)lirilis.  Ivxccssivc"  acidity  would 
account  tor  irritation  of  the  Madder  and  t'reciuent  urination.  Micro- 
sco|)i<'ai  examination  may  locate  the  existence  oF  disease  in  either  the 
kichiey,  ureter,  or  l)hi(lder. 

2.  Inspection,  Palpation,  and  Percussion  may  disclose  the  presence 
of  an  enlaruvd  lloatiui;-  or  loose  kidney,  'i'hcsc  physical  sifijns  should 
he  taken  toyether  with  the  urinary  fin(lin<;s  and  tlie  sym])tom  <ironp 
usually  associated  with  these  conditions. 

Palpation,  percussion,  and  inspection  over  the  hypo<^astrium  may  give 
strong  evidence  of  distention  of  the  bladder;  further  evidence  would 
he  the  bulging  of  the  anterior  vaginal  wall  tow'arfl  the  vulva,  and  con- 
stant dribbling  of  urine.  The  evacuation  of  a  large  (juantitx'  of  urine 
through  the  catheter  would  be  proof. 

Pal])ation  with  conjoined  examination  may  show  a  tumor  in  the 
l)ladder.  ^'aginal  and  rectal  touch  also  may  give  much  information 
relative  to  the  urethra,  bladder,  and  ureter.  Vaginal  touch  will  enable 
one  to  judge  of  sensiti\'eness  in  the  urethra  and  neck  of  the  })la(lder. 
In  the  anterior  wall  of  the  vagina  to  either  side  of  the  median  line  the 
ureter  may  often  be  felt  as  it  passes  in  a  posterior  and  lateral  direction 
on  either  side  of  the  cervix  toward  the  kidney.  It  is  normally  a  flattened, 
cord-like,  soft,  yielding  band.  Pathological  changes  sometimes  may 
make  it  easy  to  recognize  as  a  hard,  round,  large  resisting -cord.  A 
bougie  introduced  through  the  urethra  into  the  ureter  facilitates  the 
palpation. .  Tenderness  along  the  line  of  the  ureter  indicates  inflamma- 
tion; this  inflammation  of  the  ureter,  when  unrecognized,  often  leads  to 
disappointment  in  the  treatment  of  cystitis. 

The  Rdnfgeii  Skiagram,  showing  the  course  and  size  of  the  ureter 
through  the  shadow-  throwai  by  a  contained  bougie,  or  after  the  injec- 
tion of  the  ureter  with  some  fluid  w^hich  throws  a  shadow^  such  as  the 
organic  combinations  of  the  silver  salts,  argyrol,  protargol,  may  render 
positive  the  diagnosis  of  stone  in  the  ureter  or  kink;?  or  cicatricial 
contractions  of  the  ureter,  or  pyelitis,  or  misformations  of  the  kidney, 
which  otherwise  at  best  could  only  be  conjectural. 

The  interior  of  the  bladder  may  be  palpated  by  the  sound  or  by  the 
finger.  The  sound  enables  one  to  judge  of  the  presence  or  absence  of 
a  stone  or  a  tumor.  Vesical  hemorrhage  following  the  introduction 
of  the  sound  indicates  the  possible  presence  of  inflammation  or  of  a 
tumor.  Palpation  by  the  finger  through  a  dilated  urethra  is  to  be 
condemned  for  two  reasons:  first,  it  gives  no  information  which  can- 
not be  obtained  better  by  means  of  the  cystoscope;  second,  permanent 
incurable  incontinence  of  urine  from  injury  to  the  urethra  occurs  in 
about  3  per  cent,  of  the  cases.  Digital  exploration,  if  made  at  all, 
should  be  made  through  a  vesicovaginal  fistula  opened  for  the  purpose. 
See  Cystotomy  for  Cystitis. 

The  presence  or  absence  of  cystocele,  urethrocele,  prolapse  of  the 
urethra,  inflammation,  and  new  growths  about  the  meatus  may  be 
recognized  by  direct  visual  examination.  See  Inflammation  of  Skene's 
Glands,  under  Vulvovaginitis. 


80  GENERA   PRINCIPLES 

3.  Urethroscopy. — The  entire  mucous  membrane  of  the  urethra 
may  be  brought  into  view  by  means  of  a  urethroscope.  There  are 
many  varieties,  most  of  them  of  the  cyhndrical  form.  The  urethro- 
scope is  inserted  with  the  obturator  the  whole  length  of  the  urethra 
and  the  mucosa  is  brought  into  view  as  the  tube  is  withdrawn.  The 
cylindrical  cystoscope  of  Kelly  answers  the  purpose,  the  only  objection 
to  it  being  its  excessive  length. 

4.  Cystoscopy  and  Ureteral  Exploration  and  Catheterization. — There 
are  two  classes  of  cystoscopes:  they  are — • 

The  cylindrical  cystoscope. 
The  electrical  cystoscope. 
The  Cylindrical  Cystoscope. — Numerous  instruments  have  been  devised 
for  inspection  of  the  interior  of  the  bladder.     It  is  the  great  merit 
of  Howard   Kelly   to    have    popularized    and   perfected    an    effective 
and  satisfactory  means  of  intravesical  inspection.    The  following  is  a 
description  of  the  instruments  and  methods  used  by  Kelly. ^ 
The  essential  features  of  the  method  are: 

1.  Atmospheric  dilatation  of  the  bladder  induced  by  posture. 

2.  Introduction  of  a  simple  straight  speculum  without  fenestrum. 

3.  Examination  of  the  interior  of  the  bladder  and  urethra  by 

reflected  light. 
The  instruments  required  are: 
A  good  light  and  a  head-mirror. 
A  urethral  dilator,  Figure  30,  a. 
A  vesical  speculum  with  an  obturator,  Figure  29,  e. 
A  suction  apparatus  to  empty  the  bladder,  Figure  31,  X. 
A  long  mouse-tooth  forceps.  Figure  30,  d. 
A  searcher  for  discovering  the  ureteral  orifice.  Figure  30,  h. 
Ureteral  bougies  and  ureteral  catheters. 
The  speculum  in  most  common  use  has  a  diameter  of  1  cm.     If 
urethral  dilatation  to  this  extent  is  painful,  one  may  produce  local 
anaesthesia  by  the  application  of  a  10  per  cent,  solution  of  cocaine  to  be 
applied  within  the  meatus  on  a  uterine  applicator  wound  with  cotton. 
In  cases  requiring  more  dilatation  and  in  very  nervous  cases  general 
ansesthesia,  especially  in  the  first  examination,  may  be  necessary. 

The  numerous  graduated  instruments  formerly  used  to  dilate  the 
urethra  are  unnecessary.  Stretching  of  the  meatus  by  the  conical 
dilator  alone  has  been  found  sufficient. 

A  full  set  of  specula  comprises  various  sizes  ranging  in  diameter 
from  5  to  20  mm.— 3-  to  f  inch.  The  latter,  according  to  Simon,  is 
the  limit  of  safe  dilatation.  For  some  urethras  it  is  doubtless  beyond 
the  limit,  and  may  so  injure  the  urethra  as  to  destroy  retentive 
power. 

The  position  of  the  patient  is  the  chief  essential.  It  may  be  the 
dorsal  or  the  knee-breast  position. 

1  The  Kelly  cystoscope  has  been  most  advantageously  modified  by  the  addition  of  a  small  electric 
bulb  with  prisms  at  the  distal  end. 


DIAGNOSIS 


81 


For  Examination  in  the  Dorsal  Position  tlie  hips  of  the  patient  must 
be  elevated  al)()Ut  twelve  inches  ahove  the  i)lane  of  the  tal)K'.  Fi<j;iire 
29.    The  speculum  now  being  introduced  tlirough  the  urethra,  the  air 


FlQUKE    20 


Cystoscopy  by  Kelly's  method;  patient  in  dorsal  position;  e.  No.  10  cystoscope,  actual  size; 
cvstoscop'?,  without  obturator;  g,  obturator. 


netnoa;  patient  in  aorsai  position;  e,  xno.  lu 
cystoscop"?,  without  obturator;  g,  obturator. 


rushes  in  and  balloons  the  bladder.     The  residual  urine  must  be  re- 
moved by  means  of  the  suction  apparatus.    Figure  31,  X.     The  entire 
6 


82 


GENERAL  PRINCIPLES 


interior  of  the  bladder  may  then  be  examined  by  Hght  reflected  from 
a  head-mirror.  The  examination  is  made  best  in  a  dark  room  by  Hght 
from  an  Argand  burner  or  electric  light. 


Figure  30 


Cystoscopy  by  Kelly's  method,  with  the  patient  in  the  knee-breast  position:  a,  urethral  dilator, 
underscored  numerals  indicate  diameters  in  millimeters:  }>,  ureteral  searcher;  c,  ureteral  catheter; 
rf,  fine  mouse-tooth  forceps  for  use  inside  the  bladder. 


The  extent  of  surface  seen  at  one  time  will  depend  upon  the  dis- 
tance of  the  eye  from  the  cystoscopy  as  well  as  upon  the  diameter 


DIAGNOSIS  83 

of  tlie  iiistruiiKMit  and  its  iR'anicss  to  the  Held  of  \  isioii.  By  sweep- 
in<;  the  c-ystoscopc  from  sidt'  to  side,  up  and  down  and  around,  all 
parts  may  ho  l)rou,ii;lit  rapidly  ant!  sucoessively  to  \ic\v.  One  ma\ 
ohserve  and  identify  a  wide  variety  of  pathological  conditions,  such  as 
jieoplasms,  infiammation,  ulceration,  scars,  dilated  vessels,  discolor- 
ation, and  foreii,'!!  bodies.  The  most  significant  i)()ints  of  observation 
are  the  trigone  and  the  openings  of  the  ureters. 

To  expose  the  trigone,  withdraw  the  .speculum  until  the  nnicous 
membrane  of  the  inner  extremity  of  the  urethra  begins  to  close  over 
it;  then  advance  it  and  slighdy  depress  the  outer  end.  The  mucosa 
at  this  point  is  usually  of  a  dark  pink  color,  in  contrast  to  the  lighter 
glistening  aptjearance  of  the  surrounding  surfaces. 

To  expose  the  ureters,  let  the  end  of  the  speculum  project  into  the 
bladder  one  centimeter,  with  its  handle  raised.  The  interureteric 
ligament  may  in  some  cases  be  recognized  by  its  slightly  raised  trans- 
verse fold  or  by  its  distinct  difference  in  color.  A  ureteral  orifice 
should  now  be  seen  by  turning  the  speculum  about  30  degrees  to  either 
side.  By  continuous  watching,  little  jets  of  urine  will  be  seen  to  spurt 
from  the  ureteral  openings  at  intervals  of  about  a  minute.  The  appear- 
ance about  the  ureteral  opening  is  variable.  In  cases  difficult  to  cathe- 
terize  it  can  often  be  recognized  by  the  periodic  spurts  of  urine;  or  it 
may  be  seen  with  great  difficulty  only  as  a  fine  slit  in  the' mucosa; 
or  the  opening  may  be  in  a  slight  depression — a  pit  or  dimple.  In 
some  inflammatory  cases  the  opening  may  be  through  an  eminence  of 
soft  granular  tissue  or  through  the  apparently  everted  ureteral  mucosa. 
If  the  ureteral  orifice  is  in  view,  the  ureteral  catheter  may  be  intro- 
duced on  one  or  both  sides,  and  the  urine  taken  directly  as  it  flows  from 
the  kidneys.  The  beginner  will  often  have  great  difficulty  in  finding 
the  ureter.  Even  the  experienced  surgeon  often  fails.  The  difficulty, 
however,  always  decreases  with  intelligent  practice. 

Examination  in  the  Knee-breast  Position. — In  many  cases,  especially 
of  stout  women,  in  which  the  bladder  does  not  readily  balloon  with  air 
in  the  dorsal  position  it  will  do  so  in  the  knee-breast  position.  Figure 
30  shows  this  position  as  modified  by  Kelly,  with  the  buttocks  directly 
over  the  calves  of  the  legs  or  ankles,  instead  of  vertically  over  the 
thighs.  This  modification  yields  better  results,  both  in  difficult  and  in 
simple  cases. 

The  examination  is  conducted  on  the  same  principles  as  in  the 
dorsal  position.  Examination  in  this  position  requires  the  end  of  the 
cystoscope  to  be  cut  off  obliquely  instead  of  transversely. 

The  Electrical  Cystoscope. — This  instrument  was  invented  by  Leiter, 
of  Vienna,  and  later  improved  by  Casper.  Both  the  Leiter  and  Casper 
instruments  carried  the  electric  light  ray  into  the  bladder  by  means 
of  refracting  prisms  at  the  external  end  of  the  tube.  In  1S7G  Xitze 
placed  the  vacuum  light  at  the  inner  extremity  of  the  tube  in  such  a 
manner  as  to  give  direct  illumination  and  to  transmit  to  the  eye  through 
a  series  of  lenses  an  exact  picture  of  the  bladder  mucosa  magnified. 
In  all  these  instruments  the  electric  current  is  furnished  either  b\-  a 


84 


GENERAL   PRINCIPLES 


battery  or  by  the  alternating  current  which  furnishes  ordinary  illumina- 
tion, after  this  has  been  modified  by  passing  it  through  a  rheostat, 


Figure  31 


Cystoscopy  and  catheterizing  the  ureters,  Kelly  method:  X,  evacuator  used  for  withdravring 
residual  urine;  F,  hand  holding  cystoscope,  as  if  for  introduction;  Z,  cotton  wound  on  stick  for 
removing  fluid  from  bladder. 


from  which  insulated  conductors  pass  through  the  tube  to  and  from 
the  lamp.    This  instrument  is  used  with  the  bladder  filled  with  water 


DIAGNOSIS 


85 


and  with  the  ])atieiit  in  the  ordinary  dorsal  i)o.sition.     Four  conditions 
are  essential  to  the  use  of  the  electrical  cystoscope: 

1.  Permeability   of  the   urethra — 5   mm. — sufficient  to   permit   the 
ready  passage  of  the  instrument. 

2.  The  cai)acity  of  the  bladder  must  he  sufficient  to  hold  not  le.ss 
than   100  c.c.  of  injected  fluid. 

;i.  The  sphincter  x'esicie  nnist  ha\e  the  power  to  retain  the  injected 
flni.l. 

Figure  32 


The  sjTinge  is  represented  here  in  hard  rubber.  An  instrument  with  metallic  barrel  and  metallic 
piston  is  preferable  because  it  permits  frequent  disinfection  by  boiling,  and  because  boiling  injures 
the  rubber  instrument.  .-1,  filling  of  bladder  with  water,  preparatory  to  cystoscopy,  by  means  of 
syringe,  to  which  glass  catheter  is  attached  by  rubber  tube;  B,  complete  syringe;  G.c,  glass  catheter 
RJ..  rubber  tube. 


4.  The  injected  fluid  must  remain  transparent,  and  not  become 
clouded  by  admixture  of  blood  or  mucus. 

Advocates  of  this  method  claim  superiority  over  the  Kelly  method 
for  the  following  reasons: 

1.  General  or  local  anaesthesia  is  less  often  necessary. 

2.  The  more  convenient  lithotomy  position  is  used  instead  of  the 
knee-breast  or  Trendelenburg  position. 

3.  The  bladder  is  distended  more  satisfactorily  by  water  than  by  air. 

4.  The  urethra  is  dilated  less  widely. 

5.  The  examination  requires  less  time  and  less  skill,  and  requires 
no  assistant. 


86 


GENERAL   PRINCIPLES 


Comparison  of  Cystoscopes. — It  is  evident  that  the  Xitze  cystoscope 
and  the  modifications  of  it,  such  as  Casper's,  are  not  superior  to  the 
Kelly  instrument  when  the  sphincter  vesicae  will  not  retain  the  injected 
fluid,  when  the  injected  fluid  becomes  turbid  and  bloody,  and  when 
the  bladder  is  so  contracted  that  it  fails  to  distend  sufficiently.  Cysto- 
scopy and  ureteral  exploration  in  women,  owing  to  the  shortness  and 
dilatability  of  the  urethra,  may  be  accomplished  satisfactorily  by 
means  of  the  simple  Kelly  cystoscope  already  described.  In  examina- 
tions of  the  male  urethra  the  prismatic  electroscope,  on  account  of 
its  magnifying  power  and  the  greater  distance  of  the  field  of  inspec- 
tion from  the  eye,  is  indispensable. 


FiGUEE    33 


Catheterization  of  left  ureter  by  Casper  cystoscope.  Upper  right-hand  figure  shows  terminal  part 
of  Casper  cystoscope,  with  lamp  and  catheter,  slightly  reduced  size.  Lower  left-hand  figure  shows 
Nitze  cystoscope,  about  one-third  natural  size. 

The  Kelly  instrument  has  the  advantage  over  the  electrical  cysto- 
scope of  not  exposing  the  bladder  to  burns;  and  of  giving  a  more 
accessible  field  for  topical  applications. 

Value  of  Cystoscopy  and  Ureteral  Catheterization. — By  means  of  the 
cystoscope  the  entire  interior  of  the  bladder  may  be  brought  into  view; 
foreign  bodies,  tumors,  and  other  pathological  changes  may  be  recog- 
nized. The  instrument  often  has  revealed  the  presence  of  stones, 
tumors,  and  ulcers  which  had  escaped  detection  by  the  sound.  Nu- 
merous cases  in  which  cystitis  is  of  only  secondary  importance  to  other 
associated  lesions,  such,  for  example,  as  tumors,  tuberculous  ulcers, 
hemorrhoids  of  the  bladder,  are  now  daily  observed  by  the  cystoscope. 
Cystoscopy  is  of  great  value  in  preventing  blind   and   meddlesome 


DLUIXOSIS 


S7 


treatment  for  a  class  of  eases  wliieli  j)r(seiit  the  subjective  sympt(»ms 
of  evstitis,  l)iit  in  wliieh  inspection  tails  to  show  any  U'sion  \vhatc\<T 


f'atheterization  of  both  ureters  by  Casper  cystoscope.  Right  ureter  has  been  catheterized  and 
cystoscopp  withdrawn,  lea-i-ine  catheter  in  ureter.  Cystoscope  again  introduced,  and  left  ureter 
beine  catheterized:  R-C.  catheter  in  right  ureter:  L-C.  catheter  being  passed  into  left  ureter;  .4  and 
B.  forceps  and  snare  for  intravesical  operations:  a.  rheophores. 

of  the  bladder  mucosa.  The  value  of  the  instrument  is  incalculable 
when  only  limited  areas  are  diseased,  as,  for  example,  in  the  mild 
inflammations  of  the  trigone  and  in  fissure  at  the  neck  of  the  bladder. 


88  GENERAL  PRINCIPLES 

Under  such  conditions  the  operator,  instead  of  treating  the  entire 
vesical  mucosa  by  means  of  injections  more  or  less  strong,  may  direct 
to  the  diseased  part  only  any  application  which  may  be  indicated. 

Figure  35 


Cystoscopy  of  phantom  bladder  through  the  Nitze  cystoscope. 


By  ureteral  catheterization  we  are  enabled  to  separate  the  urine  of 
the  one  kidney  from  that  of  the  other,  and  temporarily,  as  it  were,  to 
eliminate  the  bladder  from  the  urinary  tract.  In  case  of  a  diseased 
kidney  marked  for  removal  one  may  demonstrate  the  presence  or 
absence  or  ascertain  the  condition  of  the  other  kidney,  and  thereby 
avoid  the  postmortem  embarrassment  of  finding  it  either  absent  or 
useless  from  disease. 

It  is  necessary  to  a  correct  diagnosis  of  cystitis,  for  example,  that 
we  know  what  abnormal  constituents  in  the  urine  have  their  origin 
within  the  bladder  itself.  Normal  urine  suffers  no  change  in  a  normal 
bladder  free  from  microbes;  hence  a  comparison  of  analyses  of  urine 
taken  from  the  bladder,  with  urine  taken  directly  from  each  kidney, 
may  at  once  indicate  the  exact  location  of  the  disease.  There  may 
be  present  the  subjective  symptoms  of  cystitis — that  is,  pjuria,  pain- 
ful and  frequent  urination,  and  ammoniacal  urine — and  yet  the  bladder 
may  be  free  from  disease. 

The  points  to  be  observed  in  urine  thus  obtained  are  the  reaction 
and  the  presence  or  absence  of  pathological  products,  such  as  pus, 
blood,  epithelial  cells,  bacteria,  and  crystals.  The  reaction  of  the 
urine  should  be  taken  at  once,  as  secondary  changes  sometimes  occur 
quite  rapidly.     If  urine  taken  directly  from  the  kidneys  possess  a 


DIAdXOSIS  89 

normal  dcfiree  of  ac'i(iity,  while  that  from  the  bladder  he  alkaline,  it  is 
evident  that  the  patholoi^ieal  process  i)roducin<i:  the  alkalinity  must  l)e 
witiiin  the  bladder.  If  urine  from  the  kidneys  be  free  from  patholoj^ical 
products,  while  that  from  the  bladder  contains  pus  epithelium,  or 
bacteria,  the  involvement  of  the  bladder  is  unquestionable. 

Exploratory   Incision 

When  other  means  of  diagnosis  have  failed,  and  it  is  necessary  to 
examine  the  ])eKic  or  abdominal  organs  directly  l)y  touch  or  by  sight, 
the  surgeon  will  for  that  purpose  open  the  peritoneum  by  exploratory 
incision.  The  incision  is  made  either  through  the  vagina — vaginal  sec- 
tion, or  through  the  abdomen — abdominal  section.  The  incision  having 
been  made,  the  finger  is  introduced  and  the  diagnosis  made  by  direct 
touch.  The  section  may  be  enlarged,  if  necessary,  so  as  to  bring  the 
pelvic  and  abdominal  contents  into  view.  Simple  touch,  however, 
through  the  incision  only  large  enough  to  admit  the  finger,  is  always 
safer  and  usually  gives  more  information  than  visual  examination.  All 
vaginal  and  abdominal  incisions  should  be  first  exploratory. 


CHAPTER   IV 

LOCAL  TREATMENT 

The  principal  procedures  in  local  treatment  are  these: 
L  The  hot-water  vaginal  douche. 

2.  Tamponade. 

3.  Topical  applications. 

1.  THE    HOT    VAGINAL   DOUCHE 

The  choice  of  the  syringe,  the  frecpiency  of  the  douche,  the  time 
and  length  of  each  application,  the  temperature  of  the  water,  the 
proper  use  of  the  bed-pan,  the  position  of  the  patient,  and  persistence 
in  the  treatment,  are  all  essential  to  good  results. 

FiGrRE  36 


UTERINE     SYRINGE;      CAPACITY     60     MIWIMS 


Some  of  the  instruments  commonly  used  in  local  treatment.     About  one-third  natural  size. 

The  small  fountain  syringe  in  general  use  requires  refilling  several 
times  during  the  application  of  the  douche.  A  large  syringe-bag  or 
receptacle  of  some  kind  to  supply  the  water  is  therefore  desirable. 
The  common  bed-pan  is  objectionable  because  it  must  frequently  be 
emptied.  To  overcome  this  difficulty,  F.  H.  Lord  attaches  a  rubber 
(90) 


LOCAL   TREATMEXT 


91 


tiihc  to  till'  l)r(l-i>;iii  tliroti.uli  wliicli  the  wntcr  is  (lr:iiii<'(|  conl  iniioiisly 
to  a  l)iicki't  Ih'Iow  the  coiicli. 

A  satisfactory  siil^stitiitc  for  tin-  hcd-pan  may  l)c  made  a>  tollows: 
at  the  side  of  ail  onliuan  bed  place  two  chairs  with  a  space  eiioiiuh 
between  them  to  admit  the  lower  bucket;  spr(>ad  a  riil)ber  sheet  o\cr 
the  side  of  the  bed  so  that  one  end  of  the  sheet  ma\-  fall  into  the  bucket 
l)elow  in  the  forn.i  of  a  troni-h.  Tlie  douche  may  then  be  >,nven  with 
the  i)atient  l\ing  across  the  bed,  the  hips  restini;-  over  the  ed^c  of  the 
l)ed  and  one"  foot' on  each  chair.  The  water  will  find  its  way  along 
the  riibl)er  troni;h  into  the  l)ncket  below. 


Rubber  sheet  substituted  for  the  bed-pan. 


The  following  is  designed  to  impress  the  importance  of  strict  ob- 
servance of  detail  in  the  application  of  the  douche.  In  no  other  manner 
will  its  sood  effects  be  realized: 


Ordinary  method  of  application 

I 

The  douche  is  applied  with  the  patient  in  the 
sitting  posture,  so  that  the  injected  water  cannot 
fill  the  vagina  and  bathe  the  cervix  uteri,  liut  in- 
stead returns  along  the  tube  of  the  syringe  as  it 
flows  in. 


II 

The  patient  is  not  impressed  with  the  impor- 
tance of  regularity  in  its  administration. 


Proper  method  of  appUcalion 


The  douche  should  invariably  be  given  with 
the  patient  lying  on  the  back,  with  the  shoulders 
low,  the  knees  drawn  up,  the  hips  elevated  so 
that  the  outlet  of  the  vagina  may  be  above  every 
other  part  of  it.  Then  the  vagina  will  be  kept 
continually  overflowing  while  the  douche  is  being 
given. 

II 

It  should  be  given  at  least  twice  every  day, 
morning  and  evening,  and  generally  the  length 
of  each  application  should  be  not  less  than 
twenty  minutes. 


92  GENERAL   PRINCIPLES 

Ordinary  method  of  application  Proper  method  of  application 

III  III 

The  temperature  is  not  specified,  or  if  specified,  The    temperature    should    be    as    high    as   the 

is  not  heeded  by  the  patient.  patient    can   endure   without   distress.      It   may 

be   increased   from   day   to   day,    from    100°    or 
105°  to  115°  or  120°  F. 

IV  IV 

The  patient  abandons  its  use  after  a  short  time.  Its  use,   in   the  majority  of   cases,   should  be 

continued    at   least    for    months.      Perseverance 
is  of  prime  importance. 

The  pressure  of  the  water  should  be  low  and  the  douche-point  short, 
for  cases  have  been  recorded  in  which  the  water  was  forced  with  un- 
fortunate results  through  the  Fallopian  tubes. 

Modes  of  Action. — The  douche  acts  in  a  twofold  way: 

1.  As  a  vascular  stimulant. 

2.  As  a  cleansing  agent. 

1.  Vascular  Stimulant. — Emmet,  the  strongest  advocate  of  the 
douche,  attributes  its  good  effects  to  the  stimulating  influence  of  the 
hot  water  on  the  blood-vessels.  The  dilated  congested  vessels  are,  he 
says,  made  to  contract,  and  in  this  way  congestion  is  lessened,  circula- 
tion quickened,  absorption  of  morbid  products  hastened,  and  local 
nutrition  improved. 

2.  Cleansing  Agent. — The  vagina  in  pelvic  inflammation  is  a  pas- 
sageway, and  to  some  extent  a  receptacle,  for  pathological  secretions. 
These  secretions  flow  into  it  from  the  uterus,  the  Fallopian  tubes,  pelvic 
abscesses,  and  from  the  vaginal  mucous  membrane  itself.  Unless 
kept  clean,  the  vagina  may  become  an  incubator  and  a  distributing- 
point  for  bacteria.  The  value  of  the  douche,  therefore,  as  a  means 
of  asepsis  is  self-evident.  When  local  disinfection  is  required,  the 
hot-water  douche  may  have  in  solution  some  antiseptic  substance, 
such  as  lysol,  one-fourth  to  one-half  of  1  per  cent,  or  boric  acid  in 
saturated  solution. 

The  Indications  for  the  douche,  as  suggested  in  the  foregoing  para- 
graphs, are  chiefly  in  the  treatment  of  chronic  pelvic  inflammations. 
The  power  of  heat  to  stimulate  and  contract  blood-vessels  makes  the 
douche  also  useful  in  the  treatment  of  uterine  hemorrhage.  The  pre- 
vailing disposition  to  extend  the  use  of  it  to  the  routine  treatment  of 
all  pelvic  disorders  should  be  discouraged. 

Contraindications. — The  douche  should  not  ordinarily  be  given 
during  menstruation  for  fear  of  exciting  pelvic  congestion,  nor  during 
pregnancy  for  fear  of  causing  uterine  contractions.  In  the  presence 
of  a  bleeding  cancer  or  sarcoma  of  the  cervix  caution  is  required  to 
avoid  hemorrhage.  In  some  cases  of  patulous  Fallopian  tubes  the 
douche  fluid  may  be  forced  into  the  uterus,  through  the  tubes  and 
into  the  peritoneal  cavity,  with  most  serious  results. 

There  are  constantly  present  in  the  normal  vagina  numbers  of 
lactic-acid-producing  bacteria  whose  function  is  to  render  the  vaginal 
secretions  acid,  and  therefore  to  make  it  an  unfit  culture-ground  for 


LOCAL   TREAT M EST 


93 


about  90  per  cent,  of  all  pathogenic  bacteria.  The  washing  out  of 
these  normal  germs  and  the  acid  secretion  may  make  the  vagina 
possibly  a  less  difficult  barrier  for  disease-germs  to  pass,  and  therefore 
may  open  the  way  for  infection  in  the  higher  /.ones  of  the  pelvis.  The 
routine  use  of  the  douche  in  the  normal  \agina  except  for  ordinary 
purposes  of  bathing  is  for  this  reason  of  questionable  propriety. 


2.  TAMPONADE 

The  principal  intlications  for  tamponade  are: 

1 .  Inflammation. 

2.  Hemorrhage. 

1.  Inflammation. — Tamponade  in  the  treatment  of  inflammation  is 
designed,  according  to  the  indication  and  manner  of  application,  to 
fulfil  one  or  more  of  three  purposes.  It  may  be  used:  (A)  as  a  means 
of  pressure;  (B)  as  a  vehicle  for  the  application  of  medicinal  substances; 
(C)  for  drainage. 

Figure  38 


^Ft5FT  LAMBS  WOOL   FOR    MAKINQ      BALL 
TAMPON;      THREAD    LYING     ACROSS. 


SAME  WITH^ENDS  FOLD 
THREAD  PARTIALLY.  TiEO. 


TAMPON    COMPLETE. 


A  a  vafiiiiul  tariipuii 


woul.      Orie-liall  luitinui  .-ize. 


A.  The  Pressure-effect  of  the  tampon  is  chiefly  useful  in  the  treat- 
ment of  displacements,  especially  displacements  due  to  inflammatory 
causes.  The  subject  will  be  discussed  further  under  the  head  of  Pelvic 
Inflammations  and  Displacements. 

B.  As  a  Vehicle  for  the  Introduction  of  Medicaments  the  vaginal  tampon 
has  become  a  routine  factor  in  gynecology.    It  is  used  most  frequently 


94 


GENERAL   PRINCIPLES 


as  a  carrier  of  glycerin.  The  effect  of  the  glycerin  is  to  cause  a  watery 
discharge  from  the  genital  tract,  and  thereby  to  deplete  the  vessels  and 
overcome  congestion.  Good  results  often  have  followed  this  treatment. 
How  far  they  should  be  attributed  to  the  tampon,  and  how  far  to  the 
curative  forces  of  nature,  or  to  associated  systemic  treatment,  it  is 


Figure  39 


VAGINAL    PACKING    WITH 
LONG    WOOL   TAMPON. 


Iritra-vitprine  application  and  vaginal  tamponade. 


often  flifficult  to  say.  If  the  tampon  is  left  in  for  more  than  twenty- 
four  hours,  it  becomes  offensive,  and  may  become  a  hot-bed  of  infec- 
tion; hence,  if  used  at  all,  it  should  be  removed  at  the  end  of  twenty- 
four  hours.  The  therapeutic  value  of  the  tampon  has  been  much 
overestimated. 


LOCAL    TULATMEXr  'J5 

C.  Drainage  of  the  Endometrium  for  I'lidonu'tritis,  by  means  of  the 
iiitra-uterine  tampon  of  aseptic  or  antiseptic  (jjanze,  has  been  a  favorite 
means  of  treatment.     See  chapter  on  Treatment  of  Endometritis. 

2.  Hemorrhage.  -  IloitorrJuujc  from  the  mijina  often  may  be  con- 
trolled by  nuaiis  of  a  tight  tampon.  It  is,  however,  })etter  to  find 
the  bleeding-point  and  secure  it  by  more  definite  surgical  means. 
Uterine  lieniorr/iagc,  whether  from  endometritis,  uterine  tumors,  or 
abortion,  may  demand  immediate  control.  The  vaginal  tam{)on  is 
used  most  conuiionly  for  this  purpose.  It  is,  howe\-er,  a  cumbersome 
measure  in  severe  cases  and  often  fails.  Great  distention  of  the  vagina 
by  a  large  tampon  interferes  with  the  function  of  the  bladder  and 
rectum,  and  is  a  mechanical  cause  of  discomfort.  The  inira-uierine 
ianiponadc  is  the  most  practical  and  the  most  effecti\e  treatment  for 
uterine  hemorrhage.  It  should  be  in  the  form  of  a  continuous  strip 
of  aseptic  or  antiseptic  gauze  two  inches  or  more  wide.  The  cervix 
having  been  exposed  by  a  Sims  speculum  and  steadied  by  a  vulsellum 
forceps,  the  strip  is  introduced  by  means  of  a  slender  dressing-forceps, 
sound,  or  similar  instrument.  The  secretions  absorbed  by  the  tampon 
decompose  rapidly,  and  become  a  prolific  source  of  infection;  hence 
the  gauze  should  be  renewed  daily  or  at  most  every  two  days.  If  as 
may  occur,  especially  in  postpartum  hemorrhage,  the  gauze  prove 
inadequate,  wads  of  cotton  may  be  substituted  advantageously. 

Material  of  the  Tampon. — If  elastic  pressure  is  required,  fine  lambs' 
wool  is  superior  to  absorbent  cotton.  For  other  purposes  the  continuous 
strip  of  aseptic  gauze  is  preferable  to  either. 


3.  TOPICAL    APPLICATIONS 

Applications  to  the  Endometrium. — Intra-uterine  medication  com- 
monly results  in  failure  and  disappointment,  for  two  principal  reasons: 
first,  it  often  is  used  in  unsuitable  cases;  second,  even  though  the  cases 
be  suitable,  it  often  is  used  improperly. 

Efficient  intra-uterine  medication  requires  that  the  medicinal  sub- 
stance be  brought  in  contact  with  the  uterine  mucosa.  Ordinarily 
the  medicament  is  carried  into  the  endometrium  when  that  cavity  is 
full  of  uterine  secretions.  These  secretions  form  a  thick  protective 
coating  over  the  mucosa.  The  application  mixes  with  and  may  ex- 
haust its  virtue  in  chemical  combination  with  the  secretions,  and  does 
not  reach  the  diseased  mucous  membrane.  If  frequently  occurs  that 
the  applicator  at  various  points  inflicts  slight  wounds  upon  the  endome- 
trium, and  thereby  opens  the  door  to  septic  invasion.  Pelvic  infection 
may  be  the  result.  The  treatment,  unless  carefully  applied,  may  be 
dangerous. 

The  prerequisites  to  safe  and  efficient  intra-uterine  applications  are: 
first,  a  clear  indication  and  definite  appreciation  of  what  the  applica- 
tion is  to  accomplish — that  is,  the  case  must  be  selected  properly; 
second,   ])reparatory    disinfection    of    the    vulvovaginal    surfaces   and 


96 


GENERAL  PRINCIPLES 


dilatation  of  the  cervix  and  cleansing  of  the  endometrium;  the  disin- 
fection is  especially  essential  as  a  precaution  against  infection. 

The  Proper  Selection  of  Cases  will  exclude,  at  least,  three  large  classes 
of  cases: 

A.  Those  cases  in  which  the  increased  uterine  discharge  is  due 
simply  to  an  effort  on  the  part  of  the  organ  to  relieve  itself  of  con- 
gestion by  increased  secretion — that  is,  cases  in  which  the  discharge 
is  not  due  to  infection.  The  congestion  of  the  mucosa  under  such  con- 
ditions is  very  apt  to  be  associated  with  some  systemic  disorder,  such 
as  cholsemia,  malaria,  diabetes,  gout,  anaemia,  or  heart  lesions.  These 
cases  should  be  treated  by  general  rather  than  local  remedies. 

Figure  40 


UTERUS     DRAWN    DOWN 
WITH    TENACULUM. 


ENDOMETRIUM 
INJECTED  WITH 
SYRINGE. 


EMMETS    DRESSING    F  O  RCEPS  WOUND   WITH   COTTON 
FOR      INTRAUTERINE    APPLICATION.  t= 


Intra-uterine  injection,  and  Emmet's  dressing-forceps  wound  with  cotton  for 
intra-uterine  application. 


B.  Those  cases  in  which  the  parametria,  Fallopian  tubes,  and  other 
circumuterine  structures  are  infected,  or  in  which  there  is  a  uterine 
or  extra-uterine  tumor,  or  some  other  anomaly  which  would  render 
topical  applications  useless  or  dangerous.  This  class  of  cases  should 
be  treated  surgically. 


LOCAL   TREATMENT  97 

C.  Those  cases  in  wliicli  the  uterine  (lischarjjje  is  due  to  some  non- 
infeetious  local  irritant  of  n()n-i)acterial  orifjin,  such,  for  example,  as 
temporary  uterine  (lis])lacemeiit  from  an  oxercrowded  bowel  or  an 
o\erdistende(l  bladder.  ^VIlen  the  local  irritation  is  remo\e(l,  the 
ilisorder  usually  disappears. 

Proper  Selection  of  Cases  for  Intra-uterine  Treatment. — For  selecterl 
ca.ses  in  which  the  uterine  mucosa  is  the  sul)ject  of  uncomplicated 
bacterial  infection,  or  in  which  the  complications  as  above  stated  are 
not  such  as  to  contraindicate  intra-uterine  medication,  it  may  be  wise 
to  introduce  medicinal  substances  to  the  endomc^trium;  the  steps  of 
procedure  will  have  to  be  as  follows: 

1.  The  pre})aratory  dilatation  (unless  the  uterine  canal  is  already 
quite  open)  and  cleansing  by  irrigation  having  been  made,  expo.se  the 
cervix  by  means  of  a  speculum,  preferably  Sims'. 

2.  Seize  the  cervix  by  means  of  a  small  tenaculum,  or  tenaculum- 
forceps,  in  the  left  hand,  and  hold  the  cervix  steady. 

3.  With  the  right  hand  pass  the  applicator,  wound  with  cotton 
which  has  been  saturated  with  the  required  medicament,  into  the 
uterine  canal;  or  if  it  be  desired  to  use  intra-uterine  injections,  the 
fluid  to  be  injected  by  means  of  a  suitable  intra-uterine  syringe. 

]Many  patients  will  not  tolerate  the  necessary  dilatation  without 
anaesthesia;  hence,  intra-uterine  medication  as  an  office  procedure 
must  be  restricted.  Within  the  limitations  above  outlined,  it  becomes 
in  many  cases  a  surgical  measure,  and  as  such  is  no  longer  a  potent 
cause  of  pelvic  infection.  The  general  subject  of  uterine  applications 
is  set  forth  more  fully  in  the  chapter  on  the  Treatment  of  Endome- 
tritis. 

It  follows  from  the  above  that  a  very  large  proportion  of  the  women 
who  formerly  were  made  the  subject  of  extensive  intra-uterine  treat- 
ment should  be  treated  rather  by  medical  or  surgical  means,  or  by 
both  combined.  ]\Iany  cases  of  excessive  uterine  secretion  which  do 
not  present  well-defined  indications  for  surgical  treatment  should  be 
relegated  to  the  field  of  internal  medicine.  The  legitimate  field  for 
routine  topical  apphcations  to  the  uterus  is  limited.  Some  gynecol- 
ogists restrict  intra-uterine  medication  almost  entirely  to  supplemental 
treatment  after  curettage,  when  a  limited  number  of  disinfecting  irri- 
gations or  applications  may  be  useful. 

The  use  of  bougies  containing  various  medicaments,  the  introduc- 
tion of  intra-uterine  suppositories,  the  injection  of  various  fluids  into 
the  uterus,  the  packing  of  the  endometrium  with  gauze,  and  other 
similar  procedures,  will,  according  to  their  value,  be  presented,  or 
omitted,  under  the  treatment  of  special  disorders.  See  Combined  Use 
of  Tents,  and  Intra-uterine  ^ledication  in  chapter  on  Elinor  Operations. 

Biers'  Cupping  Treatment.  —  Biers  and  others  practise  a  method 
of  dry  cupping  the  cervix  uteri  by  means  of  a  suction  pump  in  order 
to  stimulate  the  circulation  of  the  organ;  it  is  called  the  congestive 
treatment  and  is  said  to  modify  the  nutrition  of  the  part  favorably  by 
modifying  the  circulation.  The  idea  is  rational,  inasmuch  as  it  tends 
7 


98  GENERAL   PRINCIPLES 

to  correct  those  morbid  conditions  which  depend  upon  faulty  circula- 
tion.   Massage  of  other  parts  is  given  on  the  same  principles. 

Applications  to  the  Vulva  or  Vagina,  including  the  vaginal  portion 
of  the  uterus,  are  indicated  for  the  cure  or  palliation  of  the  various 
inflammatory  affections  of  those  organs.  Ointments,  lotions,  douches, 
and  strong  caustics  may  be  applied  precisely  as  they  would  under 
similar  conditions  to  other  parts.  See  Treatment  of  Vulvovaginitis, 
Chapter  XL 

Direct  treatment  to  the  urethra,  bladder,  and  ureters  will  be  dis- 
cussed in  Chapter  XXL,  on  Inflammation  of  the  Urinary  Organs. 

Other  forms  of  local  treatment,  such  as  scarification,  leeching,  and 
electrotherapeutics,  are  of  little  value,  and  in  the  indiscriminate  hand 
are  of  much  harm. 


CHAPTER   V 

MINOR  OPERATIONS 

Minor  surgery  involves  a  consideration  of  the  preparatory  treat- 
ment, the  operating-table,  instruments,  and  appliances,  including 
sutures,  ligatures,  and  dressings,  the  time  and  place  oi  oi)eration, 
operative  technique,  and  a  discussion  of  the  more  common  plastic 
operations   and   dilatation   and    curettage. 

PREPAEATORY   TREATMENT 

The  preparation  for  an  operation,  largely  a  matter  of  antiseptics 
and  asepsis,  is  set  forth  in  Chapter  II. 

Faulty  nutrition  from  any  cause,  such  as  syphilis,  gout,  rheumatism, 
nephritis,  diabetes,  or  purpura,  may  interfere  with  the  success  of  an 
operation,  and  may  therefore  call  for  systemic  and  hygienic  treatment. 

WHEN    TO    OPERATE 

Although  it  is  a  general  rule  not  to  operate  during  menstruation, 
it  has  by  no  means  been  proved  that  operations  are  more  dangerous 
during  this  period.  When  menstruation  is  so  long  continued  or  so 
profuse  as  to  endanger  life  or  health,  immediate  operation  may  be 
imperative.  The  presence  of  menstrual  fluid,  however,  is  unfavorable, 
though  usually  not  a  bar  to  union  by  first  intention  in  a  uterine  opera- 
tion. An  operation  performed  immediately  upon  the  close  of  men- 
struation might  cause  it  to  reappear;  if  too  near  the  anticipated  period, 
it  might  excite  a  premature  flow.  One  may  operate  safely  between 
the  third  day  after  the  close  of  one  period  and  the  tenth  day  before 
the  anticipated  appearance  of  the  next. 

The  question  of  primary  or  secondary  operations  after  puerperal 
lacerations  has  been  much  discussed.  Emmet's  operation  for  lacera- 
tion of  the  cervix,  unless  there  be  hemorrhage  from  the  torn  surfaces, 
is  delayed  ordinarily  until  after  the  puerperium.  ^Nlany  successful 
cases  of  immediate  operation,  however,  have  been  reported.  For 
laceration  of  the  perineum,  however  extensive,  the  immediate  operation 
is  desirable  for  two  reasons:  The  torn  parts  can  be  adjusted  accurately 
to  their  former  relations,  which  is  almost  impossible  in  the  secondary 
operation;  and  the  operation,  if  well  performed,  generally  results  in 
union,  and  thereby  protects  the  patient  against  septic  infection  through 

(99) 


100  GENERAL  PRINCIPLES 

the  torn  surfaces.  The  writer,  therefore,  would  ach'ise  the  primary 
operation  of  perineorrhaphy  even  as  late  as  two  days  after  delivery. 
He  has  operated  repeatedly  on  the  second  and  third  days,  and  once 
on  the  ninth,  and,  with  scarcely  an  exception,  the  delayed  operation 
has  resulted  in  satisfactory  union.  If,  however,  the  primary  operation 
has  been  delayed  for  a  number  of  days,  it  is  best,  before  introducing 
the  sutures,  to  denude  ^ath  the  curved  scissors  a  narrow  strip  all  around 
and  over  the  torn  surfaces,  in  order  that  fresh  surfaces  may  be  brought 
together.  A  delay  of  a  few  hours  after  labor  insures  greater  freedom 
from  capillary  oozing,  which  sometimes  occurs  after  closure  of  the  wound, 
and  which  may  prevent  union.  ^Moreover,  if  anaesthesia  be  required,  it 
is  better  to  wait  for  permanent  retraction  of  the  uterus;  otherwise  the 
anaesthetic  may  cause  relaxation  and  consequent  uterine  hemorrhage. 

It  is  the  duty  of  the  accoucheur  at  the  close  of  the  puerperium  to 
examine  the  uterus,  vagina,  and  perineum,  and  to  repair  any  significant 
laceration  or  injury  before  evil  results  have  developed  from  it.  Opera- 
tions may  be  necessary  even  during  lactation.  The  child  should  be 
kept  from  the  breast  only  until  the  mother  has  recovered  fully  from 
the  ansesthetic. 

Operations  during  Pregnancy  should  be  restricted  to  cases  of  immedi- 
ate and  urgent  necessity.  Plastic  operations,  as  a  rule,  may  be  deferred. 
Tumors  connected  with  the  reproductive  organs,  such  as  carcinoma 
of  the  cervix  uteri,  ovarian  cyst,  uterine  polypi,  vaginal  tumors,  vulvar 
and  rectal  tumors,  may  have  to  be  removed.  The  danger  of  abortion 
following  operations  during  pregnancy  is  due  chiefly  to  possible  sepsis 
or  to  some  other  form  of  toxaemia;  even  the  toxaemia  of  diffusible 
poisons  and  drugs,  such  as  iodine,  carbolic  acid,  bichloride  of  mercury, 
quinine,  and  the  bromides,  may  induce  abortion;  hence  the  use  of  such 
drugs  should  be  limited  and  judicious. 

Multiple  Operations. — When  several  operations  are  necessary,  it 
may  be  proper  to  perform  them  at  one  sitting.  A  rapid  operator  may 
perform  safely  dilatation  of  the  uterine  canal,  curettage,  trachelor- 
rhaphy, elytrorrhaphy,  perineorrhaphy,  and  the  removal  of  hemor- 
rhoids at  one  time.  This  amount  of  operating  at  one  sitting  would 
hardly  be  permissible  for  a  slow  operator  or  a  beginner.  The  dura- 
tion of  an  operation  should  usually  be  less  than  an  hour  and  a  half  or 
two  hours.  Abdominal  section  or  vaginal  section  is  combined  some- 
times with  plastic  vaginal  work.  This  combination,  except  in  the  hands 
of  a  rapid  and  expert  operator,  is  not  approved. 


INSTRUMENTS    AND    APPLIANCES 

Operating-tables 

For  vaginal  operations  the  table  should  be  approximately  forty- 
eight  inches  long,  twenty-four  inches  wide,  and  twenty-seven  inches 
high.     Operations   in   private  houses  are  performed   usually   on  the 


MINOR  OPERATIONS  KM 

cominoii  kitclicii  tahlc  or  laiiiidry  taMc.  or  ii])()n  tlic  narrow  diiiiii^- 
tal)!i'.  Tlif  l('n<;t!i  of  the  tahlc  should  not  he  ^Tcatcr  than  that  <ii\cn 
al)o\(',  for  when  the  thi<;-hs  aro  llcxi'd  and  the  patiiMit  drawn  toward 
the  oj)CTator  the  head  should  not  l)e  too  far  from  the  ana'sthetizer,  who 
stands  at  the  end  of  the  table  opposite  the  operator.  While  the  patient 
is  being  antiesthetized  the  feet  and  legs  may  rest  temporarily  on  a  ehair 
or  small  stand  at  tlie  foot  of  the  table. 

('l'.)vcr\s  crutch  is  one  of  the  best  of  numerous  (le\'iees  to  hold  the 
thighs  flexed  and  the  legs  in  position  during  those  vaginal  operations 
whieii  are  done  with  the  patient  in  the  dorsal  position.  Such  an  appa- 
ratus is  com  I  iiient,  but  unnecessary,  for  the  knees  may  be  held  by  two 
assistants,  one  on  each  side. 

Acute  synovitis  of  the  knee-joint  followed  by  anchylosis  has  occa- 
sionally been  observed  to  follow  vaginal  operations.  This  was  un- 
explained until  E.  H.  Webster,  of  Evanston,  Illinois,  suggested  that 
an  assistant,  while  holding  the  thighs  in  this  flexed  position,  might 
carelessly  throw  his  weight  upon  the  leg,  or  lean  heavily  upon  it,  and 
thereby  flex  the  joint  to  a  dangerous  degree. 

All  gynecological  tables,  w^hether  used  for  examination  or  operation, 
should  be  made  as  suggested  in  Chapter  III.,  with  an  inclination  of 
three  or  four  inches,  the  foot  of  the  table  being  to  that  extent  abo\'e 
the  level  of  the  head  of  it.  - 

Other  accessories  to  the  operating-table  include  knee-rests,  rubber 
sheets,  and  smaller  tables  for  instruments,  dressings,  and  ligatures. 


Instruments 

Sims'  Speculimi  and  Simon's  Speculum  have  been  described  in  the 
chapter  on  Diagnosis.  For  operations  on  the  vaginal  walls,  such  as 
the  closure  of  vaginal  fistulse,  repair  of  the  lacerated  cervix,  division 
of  the  cervix,  dilatation  of  the  cervix,  and  curettage,  Sims'  speculum 
is  regarded  generally  by  all  who  have  familiarized  themselves  with 
its  use  as  the  preferable  instrument.    See  Chapter  III. 

Simon's  speculum,  though  for  plastic  vaginal  work  often  inferior  to 
Sims',  is  yet  for  some  purposes  a  more  practical  instrument.  It  has 
one  advantage  over  Sims' — i.  e.,  the  patient  being  in  the  dorsal  posi- 
tion, on  a  Kelly  pad  or  rubber  sheet,  the  operation  may,  with  Simon's 
speculum,  be  done  under  constant  vaginal  irrigation.  Simon's  instru- 
ment and  the  dorsal  position  are  superior  to  Sims'  and  the  lateroprone 
position  for  all  operations  in  which  the  pelvic  cavity  is  to  be  opened 
through  the  vagina,  such,  for  example,  as  vaginal  hysterectomy,  vaginal 
salpingectomy,  and  vaginal  ovariotomy. 

Vulsella  Forceps  similar  in  construction  to  those  shown  in  Figure  48 
are  useful  in  various  operations  on  the  uterus  and  about  the  cervix. 
They  serve  to  grasp  and  draw^  down  the  cervix,  to  grasp  an  intra- 
uterine tumor,  and  to  steady  the  cervix  during  the  passage  of  a  suture 
or  during  curettage. 


102 


GENERAL  PRINCIPLES 

Figure  41 


MIXOR  OI'EHATIOXS  103 

Scissors.— The  minor  gynecological  operations  may  he  performed 
either  with  the  scissors  or  with  a  knife.  The  choice  depends  miicji 
upon  the  education  and  habits  t)f  the  ojKTator.  The  scissors  cause- 
less hemorrhage,  and  when  one  becomes  accustomed  to  their  use  he 
can  work  more  accurately  and  more  rapidly.  Any  strong,  well-made, 
slightly  curved  scissors  will  suffice,  but  those  of  Emmet  are  adapted 
especially  to  intravaginal,  perineal,  and  vulvar  oi)erations. 

Emmet's  slightly  and  fully  curved  scissors  are  almost  indispensable 
for  denuding  in  plastic  operations.  Figure  42;  the  slightly  curved  are 
used  for  perineal  and  for  ordinary  intravaginal  denudation;  the  strongly 
curved  are  convenient  for  denuding  a  strip  high  up  across  the  vagina 
or  cervix  uteri  in  fistula  and  cervix  operations.  These  scissors  are 
curved  toward  the  left,  and  are  intended  to  be  used  in  the  right  hand. 
Emmet  mentions  also  two  others,  with  curves  to  the  right;  but  it  is 
scarcely  possible  to  imagine  an  operation  in  which  the  latter  would  be 
necessary.  In  ordering  these  scissors  one  should  be  careful  to  explain 
that  he  wants  those  which  are  curved  to  the  left  for  use  in  the  right 
hand;  otherwise  the  instrument-maker  will  send  those  which  curve 
to  the  right  for  use  in  the  left  hand.  In  fact,  a  good  deal  of  confusion 
has  arisen  in  this  matter,  and  consequently  orders  often  are  filled  with 
scissors  which  are  useless. 

Sponge-holders. — Ordinary  haemostatic  forceps  with  handles  eight 
inches  long  serve  the  purpose  of  sponge-holders  much  better  than 
instruments  made  expressly  for  the  purpose. 

Uterine  Tenaculum. — Numerous  tissue-forceps  have  been  devised 
for  grasping  the  tissues  to  be  denuded  or  excised,  but  a  properly  con- 
structed tenaculum  in  the  educated  hand  is  the  most  convenient  and 
effective  instrument  for  this  purpose.  With  the  tenaculum  the  operator 
can  pick  up  and  hold  a  smaller  amount  of  tissue,  and  therefore  can 
denude  more  superficially  than  is  possible  with  the  tissue-forceps. 
The  instrument.  Figure  42,  has  a  perfectly  straight  hook  a  little  more 
than  a  quarter  of  an  inch  long  and  bent  at  right  angles  to  the  shaft. 
It  should  be  so  strong  and  stiff  that  considerable  force  may  be  applied 
in  the  line  of  the  instrument  without  breaking  or  bending  the  hook, 
or  in  a  lateral  direction  without  bending  the  shaft.  The  uterine  ten- 
aculum is  useful  not  only  in  denudation,  but  also  in  almost  every  step 
of  a  gynecological  examination  or  operation.  In  some  operations  as 
many  as  four  of  them  may  be  required. 

Needles. — A  round  needle  is  preferable  to  one  with  a  cutting  edge. 
The  incised  wound  made  by  the  latter  is  generally  too  large  for  the 


Explanation  of  Figure  41 

a.  Ligature  applied  in  this  manner  may  slip.     Reduced  one-half. 

b.  Ligature  applied  in  this  manner  cannot  slip.    Catgut  tied  in  this  manner  not  apt  to  become  loose. 
Reduced  one-half. 

r.  The  forceps  grasping  the  needle  over  the  eye  is  apt  to  crush  it. 

</.  The  forceps  grasping  the  needle  in  this  way  does  not  hold  it  firmly. 

e.  Correct  grasp. 

f.  g,  h.  i.   Different  forms  of  needles.     Ordinarj-  size. 

j,  k,  I.  m.   Needle-points  of  different  varieties,  magnified. 


104 


GENERAL  PRINCIPLES 


suture,  bleeds  freely,  is  prone  to  suppurate,  and  requires  more  time 
for  healing.    The  punctured  wound  made  by  the  former  readily  shrinks 


FiuuHE  42 


'emmets  needle   forceps    j^SIZE.*^ 


A,  deuudiug  a  surface  with  Emmet's  curved  scissors;  B,  C,  suturing  a  wound. 


down  upon  the  suture,  is  less  liable  to  bleed  or  to  suppurate,  and, 
after  removal  of  the  suture,  heals  more  .quickly.    The  tissue,  especially 


MfXOh'  ni'ERATfOXS  105 

ill  the  ('er\ix  iitori,  is,  howoxcr,  often  so  (Iciise  as  to  necessitate  the  use 
ol'  a  needle  with  a  cutting  eclj^e. 

Many  of  the  most  dexterous  operators  prefer  tlie  straight  ncedh- 
to  the  eur\'ed.  'I1ic  straight  needle  has  two  advantages:  first,  how- 
ever (l(>eply  it  may  he  buried  in  the  tissues,  the  i)ositioii  of  its  point 
can  always  he  deteruiined  from  its  direction  and  length;  second,  the 
force  necessary  to  introduce  it  heing  in  the  direction  of  the  needle,  it 
is  nuich  less  than  that  recjuired  to  introduce  a  cur\ed  needle,  for  that 
force  must  he  applied  on  the  tangent  to  the  curve;  hence,  the  thickness 
of  the  curved  needle  must  be  greater  in  order  to  avoid  breaking.  The 
straight  needle,  in  a  word,  requires  less  force  for  its  introduction,  is 
less  liable  to  break,  and  makes  a  smaller  wound.  The  {)lain  round 
point,  however  sharp,  sometimes  encounters  great  resistance  in  passing 
through  dense  tissues.  The  trocar-point  or  the  saddle-point  represented 
in  Figure  43  is  less  objectionable  than  the  cutting  edge,  and  may  be 
introduced  almost  as  easily. 

Various  needles  with  handles  attached  or  detached,  and  of  different 
curves  and  shapes,  have  beeu  devised,  some  with  eyes  at  their  points, 
some  without  eyes,  and  others  of  cylindrical  form,  through  which  the 
suture  is  passed  lengthwise  from  one  end  to  the  other.  They  complicate 
rather  than  simplify  an  operation,  and  are  in  no  respect  superior  to 
the  simple  needle  and  thread. 

Operative   Technique 

Plastic  Operations. — The  subject  of  plastic  operations  comprehends 
all  operations  for  the  repair  of  lacerations  of  the  cervix  and  perineum, 
and  of  vaginal  fistula?;  it  also  includes  certain  operations  on  the  vaginal 
walls  known  as  elytrorrhaphy,  and  numerous  operations  on  the  urethra, 
vulva,  and  anus. 

A  clear  appreciation  of  the  causes  of  failure  will  contribute  to  success 
in  plastic  surgery.  Two  principal  causes  of  failure  are:  first,  parts 
which  never  ought  to  be  united  are  brought  often  into  apposition; 
second,  faulty  technique  may  result  in  failure  of  union. 

One  of  the  most  common  bad  results  of  the  repair  of  the  lacerated 
cervix  uteri  or  perineum,  for  example,  is  the  union  of  parts  which  were 
not  together  before  the  injury,  and  cannot  be  untied  without  harm. 
Commonly  a  plastic  operation  which  results  in  union  is  called  successful. 
If,  however,  there  has  been  union  of  wrong  parts,  actual  harm  may 
have  been  done.  The  flap-splitting  operation  of  perineorrhaphy,  for 
example,  too  often  gives  such  a  result. 

Union  by  First  Intention  will  result  almost  always  from  a  correct 
operation.  True,  in  certain  cases  of  vaginal  fistula  in  which  there  has 
been  great  loss  of  tissue  from  sloughing,  failures  may  arise  from  the 
cicatricial  character  of  the  parts  or  from  difficulty  in  holding  the  edges 
together.  In  very  fat  subjects  perineorrhaphy,  especially  when  the 
rupture  extends  through  the  sphincter  ani  muscle,  may  fail  even  after 
the  most  skilful  operation.     Certain  systemic  diseases,  among  them 


106  GENERAL  PRINCIPLES 

diabetes,  are  unfavorable  for  union.  Generally  the  conditions  of  success 
are  within  the  control  of  the  operator.  He  should  put  the  parts  to  he 
united  in  such  a  condition  that  non-union  woidd  he  contrary  to  nature. 
These  conditions  are  simple,  but  absolute;  and  the  operator  who  has 
neglected  them  can  neither  fairly  attribute  his  failure  to  the  debilitated 
state  of  the  patient,  nor  to  chance,  nor  to  accident.  Indeed,  union  almost 
invariably  follows  if  the  surfaces  to  be  united  are  prepared  properly 
and  kept  in  contact  for  a  week.  The  first  condition,  asepsis,  has  been 
discussed.     The  others  will  be  presented  in  the  following  paragraphs. 

Denudation. — The  patient  having  been  etherized,  placed  in  posi- 
tion, and  the  field  of  operation  exposed,  the  surfaces  to  be  united 
should  be  denuded.  Correct  denudation  is  a  prerequisite  to  healing 
by  first  intention.  Surfaces  to  be  united  should  be  so  denuded  that 
when  brought  together  they  will  fit  accurately,  otherwise  a  part  of 
the  denuded  surface,  being  in  contact  with  an  undenuded  surface, 
must  heal  by  granulation  and  suppuration,  which  may  irritate  the 
rest  of  the  wound  excessively,  and  always  produces  cicatricial  tissue, 
which  is  very  objectionable.  The  denuded  surface  should,  moreover,, 
be  smooth  and  free  from  shreds,  which  might  die  and  become  sources 
of  septic  infection.  E\'ery  particle  of  membrane  or  skin  within  the 
area  of  denudation  should  scrupulously  be  removed.  If  the  surface 
be  perfectly  healthy,  the  more  superficial  the  denudation  the  better; 
but  diseased  and  cicatricial  tissues  do  not  unite  readily,  and  should 
therefore,  when  practicable,  be  removed. 

Figure  43  shows  the  action  of  the  tenaculum  and  scissors  in 
denuding.  The  superiority  of  the  tenaculum  as  a  substitute  for  the 
tissue-forceps  -must  become  apparent  to  anyone  who  will  familiarize 
himself  with  its  use. 

How  to  Handle  a  Needle-forceps. — The  simple  rotation  of  the 
needle-forceps  on  its  long  axis  by  a  turn  of  the  wrist  enables  the  operator 
to  sweep  the  straight  needle  around  a  curve  in  the  vertical  plane,  or  it 
may  be  carried  around  a  curve  in  the  horizontal  plane  by  loosening  and 
tightening  the  forceps'  grasp  upon  the  needle  at  very  short  intervals, 
so  that  the  angle  between  the  forceps  and  the  needle  may  change  almost 
constantly  during  the  passage  of  the  needle.  In  this  way  the  straight 
needle  may  be  made  to  carry  a  suture  around  a  curve  more  accurately 
than  the  curved  needle,  and  often  more  easily.  Obviously,  the  lock- 
forceps,  which  do  not  permit  of  this  freedom  of  motion,  are  unsuited 
to  such  manipulations.  Figure  42  represents  Emmet's  needle-forceps 
without  lock. 

Sutures. — The  most  practical  materials  for  sutures  are  silkworm- 
gut  and  catgut.  The  peculiar  advantages  of  each  will  be  presented 
in  the  description  of  special  operations.  Before  the  introduction  of 
the  sutures  approximate  the  denuded  surfaces  with  tenacula  to  deter- 
mine whether  they  are  of  such  size  and  shape  that  the  union  will  pro- 
duce the  desired  result,  and  whether  accurate  coaptation  of  the  margins 
can  be  secured  without  undue  traction,  which  might  cause  the  suture 
to  cut  out;  then  hook  up  the  margin  of  the  wound  with  a  tenaculum. 


MlXOIi  ()l'Kh'.\T/().\S 


107 


introduce  the  lurdlc.  and  ai)])l\  couiitcrprt-ssurc,  Fiffiire  42,  (',  Ji, 
until  the  needle-point  can  he  seized  and  drawn  throutrh  with  the  l'oree|)s. 
Some  ojjerators  use  the  hluut  hook  for  eounterj)ressure;  hut  a  stronj; 
tenaeuluin  which  will  neither  i)reak  nor  bend  is  preferahle,  especially 
in  dense  uterine  tissue,  heeause  it  nia\'  also  be  fixed  in  the  tissues  at 
the  very  j)oint  where  the  ()i)erator  desires  to  force  the  needle  throuf^h, 
and  it  thcrebx"  insures  <rreat(T  precision  in  directin<i:  the  needle  to  tin 
|)oint  of  exit. 


Removing  a  suture. 

In  making  counterpressure  the  tenaculum  may  slip  and  the  uterus 
receive  a  violent  and  sudden  jerk,  which  is  not  without  danger,  espe- 
cially w-hen  often  repeated;  this  may  be  avoided  and  the  operation 
facilitated  by  holding  the  flap  in  the  vulsellum  forceps  while  the  needle 
is  being  forced  through  between  its  teeth. 

Sutures  should  be  about  one-fourth  of  an  inch  apart,  should  include 
considerable  tissue,  and,  if  practicable,  should  pass  entirely  under,  not 
through,  the  denuded  surface,  so  as  not  to  be  in  contact  with  any  por- 
tion of  the  wound.  When  at  a  distance  from  the  denuded  surface 
they  are  less  liable    to  irritate  and  give  rise  to  swelling  and  infection. 

Ligatures.— Generally  speaking,  catgut  is  recognized  as  the  best 
material  for  ligatures. 


108 


GENERAL  PRINCIPLES 


The  Staffordshire  Knot. — It  is  sometimes  necessary  in  minor  and  major 

operations  to  apply  a  ligature  en  masse.  In  many  cases  this  ligature 
may  to  great  advantage  take  the  form  of  the  Staffordshire  knot.  This 
knot  will  be  found  especially  applicable  to  the  ligating  of  hemorrhoids. 
The  application  of  it,  Figure  44,  is  as  follows:    The  part  to  be  ligated 


Figure  44 


Technique  of  the  Staffordshire  knot.     One-third  natural  size. 

is  transfixed  with  the  needle  and  the  needle  withdrawn  so  as  to  leave 
the  loop  of  the  thread  on  the  farther  side  of  the  stump  a.  The  loop 
then  is  drawn  over  the  mass  to  be  ligated  and  one  of  the  free  ends  drawn 
through,  so  that  one  free  end  is  under  and  the  other  over  the  retracted 
loop,  h  and  c;  both  free  ends  being  seized  by  the  right  hand  are  drawn 
tightly  through  the  mass  while  the  thumb  and  forefinger  of  the  left 
hand  grasp  the  ligature  where  the  free  ends  cross  the  loop  and  make 
firm  counterpressure  against  the  mass  until  complete  constriction  is 


MIXOR  oriCh'ATIOXS  109 

secured,  d.  Finally,  the  ligature  is  tied  securely,  e.  It  then  may  he 
passed  around  the  pedicle  and  tied  again.  The  ad\antagc-s  of  the 
knot  are:  ( 1 )  it  ties  the  pedicle  in  two  liaKcs;  (2)  these  halves  are 
uniformly  and  strongly  compressed  into  one  mass.  It  is  cpiite  essential 
to  draw  the  ligature  very  tight  and  to  retain  the  constriction  thereby 
secured  until  the  knot  is  tied. 

The  sutures  should  he  tied  with  the  greatest  care,  and  should  he 
drawn  just  tightly  enough  to  hold  the  denuded  surfaces  in  contact. 
If  drawn-  too  tightlx',  the  tissue  will  become  strangulated  and  swollen, 
the  sutures  will  cut  out,  and  the  operation  may  fail. 

Before  tying  a  suture  the  bleeding  should  be  stopped;  otherwise 
small  quantities  of  blood  may  acciunulate  in  the  track  of  the  wound 
and  serve  as  a  mechanical  bar  to  union.  A  constant  stream  of  hot, 
sterilized  water  playing  on  the  wound  during  the  tying  of  the  sutures 
is  desirable 

This  knot  is  very  serviceable  in  tlie  ligature  of  hemorrhoids. 

Removal  of  Sutures. — Ordinarily  the  sutures  should  be  removed 
at  the  end  of  a  period  varying  from  ten  to  fifteen  days;  if  suppuration 
occur,  earlier.  Sutures  about  the  vulva  and  permeum  should  be  re- 
moved in  about  ten  days.  If  left  much  longer,  they  may  become 
loose  or  cause  suppuration.  In  the  vaginal  walls  they  may  be  left 
several  days  longer.  In  the  cervix,  where  suppuration  seldom  occurs, 
they  should  be  removed  in  about  two  weeks,  unless  perineorrhaphy 
has  been  done  at  the  same  time,  in  which  case  removal  cannot  safely 
be  undertaken  in  less  than  three  or  four  weeks.  To  remove  a  suture, 
seize  the  free  end  with  a  forceps,  and  with  the  scissors  cut  the  nearest 
side  of  the  loop.  Cutting  the  nearest  side  tends  to  hold  the  edges 
of  the  freshly  united  wound  together  during  the  withdrawal  of  the  suture; 
if  the  loop  were  cut  on  the  farther  side,  removal  would  tend  to  reopen 
the  wound.  It  is  well  to  seize  with  the  forceps  only  one  of  the  free  ends, 
for  the  other  will  then  be  available  in  case  this  one  is  cut  off  accidentally. 
Always  make  sufficient  traction  to  bring  the  loop  in  sight  before  cutting, 
otherwise  both  sides  may  be  cut  off  below  the  knot  and  the  loop  left. 
If  then  the  ends  of  the  loop  retract,  as  they  usually  do,  the  loop  may 
remain  indefinitely,  keep  up  constant  suppuration,  and  finally  have  to 
be  removed  under  anaesthesia  by  incision. 

Dilatation  and   Incision 

The  cavity  of  the  uterus  may  be  made  surgically  accessible  to  the 
examining  finger  or  to  instrumentation  by  dilatation  or  incision.  The 
indications  may  be  diagnostic  or  therapeutic,  or  both.  Among  these 
indications  are  stenosis  or  stricture  of  the  canal,  uterine  hemorrhage 
due  to  endometritis,  neoplasms,  al)ortions,  and  pathological  antefiexions. 

Dilatation  is  accomplished  by  tents,  c/raduaterl  bougies;  sounds  and 
instru)nents  with  diverging  blades. 

Tents. — Sponge,  tupelo,  and  sea-tangle  are  the  materials  of  which 
tents  commonlv  are  made;  if  the^■  are  introduced  into  the  uterus  in 


no 


GENERAL  PRINCIPLES 


the  dry,  compressed  state,  the  mucous  secretion,  stimulated  by  their 
presence,  causes  them  to  swell  laterally  to  the  extent  of  two  or  three 
diameters,  and,  correspondingly,  to  dilate  the  canal. 


Figure  45 


Dilatation  by  graduated  bougies.     Six  gradually  increasing  sizes  shown  in  the  three  instruments 
at  the  lower  part  of  the  illustration.     One  end  of  each  dilator  is  slightly  larger  than  the  other. 


The  danger  of  sepsis  after  continuous  dilatation  by  introducing  one 
tent  after  another  is  very  great.  Alarming  results  often  have  fol- 
lowed the  use  of  the  second  or  the  third  tent,  seldom  the  first.  A  tent 
should  not  under  any  circumstances  be  allowed  to  remain  in  the  uterus 
more  than  twelve  hours.  The  tents  furnished  by  instrument-makers 
are  usually  not  aseptic.  Before  using  them,  therefore,  it  is  always  well 
to  subject  them  to  the  dry-heat  process  of  Boeckmann,  as  described 


MIXOh'  OI'Eh'ATIONS  111 

in  ('h;ii)t('r  II.  tor  tin-  disiiit'cctioii  of  catj^ut.  After  the  remo\al  of  a 
tent  the  endonietriiini  should  hi'  washed  out  with  sterile  water,  and 
disinfected  with  a  topieal  apphcation  of  a  stronj^  sohition  of  iodine  in 
95  per  cent.  carboHc  acid;  this  application  should  be  made  by  means 
of  an  applicator  wound  with  cotton.  The  danger  of  tnj'crfion  from  tent.s 
US'  .s'o  (/rrat  that  the  use  of  them  generally  if  diaapprored.  This  danger, 
howe\er,  is  iarijely  obviated  by  a  device  described  as  follows: 

The  Combined  I'.se  of  Tents  and  Intra-uterine  Medication.^ — Dilata- 
tion of  the  uterus  by  means  of  tents  and  treatment  by  intra-uterine 
applications  made  up  a  very  large  part  of  the  gynecolo<jical  therapeutics 
of  a  former  generation.  Both  of  these  measures  have  fallen  into  almost 
universal  disuse;  the  tent,  although  of  great  diagnostic  and  therapeutic 
value,  having  been  discarded  because  of  the  frequent  disabling,  not  to 
say  fatal  metritis,  salpingitis,  and  peritonitis,  which,  even  under  the 
most  careful  and  judicial  handling,  occasionally  followed  its  use.  The 
old  routine  intra-uterine  applications  as  used  in  the  office  or  in  the 
patient's  house  were  condemned,  not  only  because  they  were  generally 
useless,  but  also  and  more  especially  because  they  were  dangerous 
and  sometimes  destructive.  Since  these  measures  have  been  relegated 
to  the  dark  ages  of  gynecology,  we  have  for  the  most  part  put  in  place 
of  them  forcible  dilatation  by  means  of  steel  instruments,  and  curettage 
under  anaesthesia.  Forcible  dilatation  popularized  by  our  late  fellow, 
Goodell,  and  others,  undoubtedly  has  wide  usefulness  when  used  with 
care  and  judgment.  Even  in  the  hands  of  the  incompetent  and  careless 
practitioner  it  will  be  less  hazardous  than  the  old  routine  treatment, 
because  it  rises  to  the  dignity  of  a  surgical  operation  and  is,  therefore, 
presumably  always  undertaken  with  aseptic  conditions  and  because 
it  is  not  so  frequently  repeated.  Forcible  dilatation  is  transient  in  its 
effect,  and,  therefore,  not  always  adequate;  furthermore,  if  carried  far 
enough  to  permit  intra-uterine  digital  touch,  which  is  often  desirable, 
serious  rupture  of  the  uterus  might  result.  The  intra-uterine  appli- 
cation of  iodine  or  other  substances  usually,  since  it  does  not  reach 
thoroughly  the  uterine  mucosa,  especially  the  uterine  glands,  gives  dis- 
appointing results.  Any  measure,  therefore,  that  will  safely  prolong 
the  dilatation  and  bring  the  application  effectively  in  contact  Tsith  the 
mucosa  and  muciparous  glands  should  be  of  value  (Figure  46). 

The  device  here  described  consists  in  the  use  of  a  tupelo-sponge 
or  sea-tangle  tent,  over  the  distal  end  of  which  has  been  attached  half 
of  a  gelatin  capsule  filled  with  whatever  medicinal  substance  may  be 
desired  for  intra-uterine  application. 

The  diagram,  with  its  explanation,  shows,  first,  the  sterile  tent  over 
the  end  of  which  has  been  placed  the  gelatin  half-capsule.  The  tent 
should  be  kept  sterile  in  a  test-tube  stopped  with  cotton  until  used. 
The  drawing  shows  also  another  tent  slightly  curved  to  facilitate  intro- 
duction and  a  half-capsule  partly  filled  with  a  medicinal  substance. 
Any  form  or  size  of  tent  may  be  used. 

'  Read  by  the  author  before  the  American  Gynecological  Society,  May  23,  1911. 


112 


GENERAL   PRINCIPLES 


Figure  46 


Therefore,  after 
expanding  tent 
secretions  which 


It  is  perhaps  well  to  lay  stress  on  the  necessity  of  thorough  disinfec- 
tion of  the  tent  and  of  keeping  it  aseptic  until  used.'  In  my  service  at 
St.  Luke's  Hospital  the  tents  are  exposed  to  a  heat  of  240°  F.  on  two 
consecutive  days  and  again  to  the  same  degree  of  heat  before  using. 

There  is  a  possible  defect  in  the  iodine  tent  as  above  described, 
that  is,  in  the  gelatin  capsule  which,  although  subject  in  the  manu- 
facture to  considerable  heat,  is  not 
aseptic  and  may  be  a  source  of 
infection.  The  difficult}'  may  be 
practically  and  perhaps  wholly  ob- 
viated by  placing  the  half-capsule 
filled  mth  iodine  on  the  end  of  the 
tent  two  days  before  it  is  to  be  in- 
troduced ;  then  the  iodine  permeates 
the  capsule  and  renders  it  probably 
safe. 

The  only  medicinal  substance  I 
have  used  so  far  is  a  combination 
of  iodine  crystals,  one  part,  and 
potassium  iodide,  two  parts,  this  be- 
ing a  proportion  which  dissolves 
readily  in  water, 
introduction,  the 
stimulates  uterine 
dissolve,  first,  the  capsule,  and 
second,  the  iodine  and  potassium 
iodide,  making  at  once  a  prolonged 
application  to  the  endometrium;  at 
the  same  time  the  iodine  permeates 
the  tent  and  renders  it  continuously 
antiseptic.  Should  the  half-capsule 
not  hold  enough  iodine,  the  other 
half-capsules  may  be  filled  and 
placed  each  over  the  end  of  the 
preceding  capsule  until  a  sufficient 
quantity-  has  been  secured. 

This  iodine  combination  dissolves 
readily  in  less  than  one-half  its 
weight  in  water ;  therefore,  the  uter- 
ine secretions  stimulated  by  the  tent 
are  quite  sufficient  to  effect  a  solu- 
tion. The  solution,  like  Churchill's 
caustic  solution,  undoubtedly  would  have  a  very  escharotic  effect  and 
might,  if  applied,  cause  stenosis  of  the  uterine  ends  of  the  Fallopian 
tubes.  It  is  also  possible  that  if  the  tubes  were  open  uterine  contrac- 
tions might  force  it  into  the  tubes  with  possible  disastrous  cauterization. 
Such  an  accident  e^^dently  would  be  more  likely  to  occur  in  conse- 
quence of  the  cervical  canal  being  tightly  plugged  by  the  tent.    I  have 


ft;i^ 


Device  for  prolonged  dilatation  of  the  uterus 
in  conjunction  with  thorough  intra-uterine  medi- 
cation, a,  a  tupelo-tent  with  gelatin  half-capsule 
attached  kept  sterile  in  a  test-tube;  b,  a  gelatin 
half-capsule  containing  two  parts  of  potassium 
iodide  and  one  part  of  iodine  crystals;  c,  a  curved 
tent  on  the  distal  end  of  which  has  been  placed 
the  half-capsule  containing  iodine  one  part  and 
potassium  iodide  two  parts,  this  being  soluble 
in  water. 


Ml  son  OPERATIONS  113 

not  applied  more  than  three  or  four  grains  of  this  combination  and  would 
hesitate  to  increase  this  amount  except  in  case  of  a  very  fiahhy  hem- 
orrliat^ic  uterus.  Manifestly  it  mi<jht  he  desirable  to  dilute  the  iorline 
combination  in  such  a  way  as  to  insure  tiie  nuicosa  aj^ainst  destructi\e 
action.  Such  a  dilution  could  be  made  with  magnesium  silicate,  that 
is,  talcum  powder,  this  being  comparatively  an  inert  substance  with 
which  the  iodinC  combined  would  have  no  chemical  reaction. 

This  ])rocedure  is  more  efhcacious  than  the  ol)S()lete  one  of  passing 
an  applicator  armed  with  medicated  cotton  into  the  uterus.  The 
explanation  is,  first,  in  the  conjunction  of  prolonged  dilatation  and  the 
continuous  application  of  the  medicinal  substance;  second,  this  applica- 
tion is  made  during  a  period  when  the  uterine  wall  is  thinned  by  dilata- 
tion, and  the  muciparous  glands  are  correspondingly  shortened  and 
opened,  and,  therefore,  are  more  accessible  to  treatment. 

I  suggest  a  trial  of  this  method  in  such  cases  of  uterine  catarrh, 
uterine  hemorrhage,  dysmenorrhea,  and  sterility  as  may  furnish  an 
indication  for  dilatation  and  intra-uterine  application.  For  obvious 
reasons  it  should  not  be  undertaken  at  the  office,  but  should  be  sur- 
rounded by  all  the  safeguards  of  a  surgical  operation  in  the  patient's 
house,  or  preferably  in  the  hospital.  The  iodized  tent  may  be  intro- 
duced as  a  supplement  to  the  forcible  dilatation  with  steel  instruments 
under  anaesthesia,  in  which  case  a  somewhat  larger  tent  may  be  used. 
If  no  general  aniesthesia  is  given,  I  suggest  the  following  technique: 

1.  Cleanse  the  vagina  to  a  degree  as  near  sterilization  as  may  be 
practicable. 

2.  Introduce  into  the  uterus  an  applicator  wound  with  absorbent 
cotton  saturated  with  a  10  per  cent,  solution  of  cocaine.  Ten  minutes 
usually  will  suffice  for  practical  local  anaesthesia. 

3.  Carefully  and  moderately  dilate  the  uterus  by  means  of  a  Palmer 
or  very  small  Goodell  dilator. 

4.  Introduce  the  tent. 

5.  In  about  twelve  hours  remove  the  tent  and  follow  it  by  a  larger 
one  if  additional  dilatation  is  desired. 

In  the  older  experience  of  dilatation  by  means  of  tents  the  dangerous 
infections  usually  followed  the  use  of  the  second  or  third  tent,  seldom 
the  first.  Under  aseptic  conditions  one  might  safely  apply  two  tents 
in  immediate  succession;  but  if  more  dilatation  were  required  I  would 
advise  it  to  be  begun  forcibly  under  anaesthesia  and  then  continued  by 
one  or  two  tents. 

]My  estimate  of  the  value  of  the  device  is  based  for  the  most  part 
on  general  principles.  I  have  used  it  only  a  few  months  and,  therefore, 
cannot  report  the  remote  results  in  concrete  cases.  In  one  case  a  mod- 
erate pelvic  inflammatory  reaction  followed  which  subsided  in  a  few 
days  apparently  without  serious  results.  This  case  serves  to  empha- 
size the  necessity  for  extreme  care  in  the  use  of  any  method  of  uterine 
dilatation  and  intra-uterine  application. 

I  make  no  extreme  claim  relative  to  the  value  or  safety  of  the  method 
I  have  described.  So  far  I  have  found  it  quite  satisfactory.  I  offer 
8 


114  GENERAL  PRINCIPLES 

it  in  a  tentative  way,  hoping  it  may  prove  useful  in  selected  cases  as 
a  supplement  or  a  substitute  for  the  more  radical  forcible  dilatation. 
At  any  rate,  it  is  about  all  I  have  been  able  to  rescue  from  the  ancient 
wreck  of  routine  intra-uterine  therapeutics,  which  filled  a  large  and 
melancholy  place  in  the  gynecological  therapeutics  of  the  last  century. 

Uterine  dilatation  by  means  of  tents  fell  under  merited  condemnation 
before  the  time  of  antiseptic  and  aseptic  surgery.  Perhaps  under  modern 
conditions  it  may  be  found  that  the  danger  was  dependent  not  on  the 
tent  itself,  but  on  the  unclean  conditions  in  which  it  was  applied. 
Comparing  the  relative  value  of  the  earlier  tent  dilatation  with  the 
later  forcible  dilatation  by  means  of  steel  instruments,  and  eliminating 
the  septic  results  which  so  frequently  followed  the  use  of  the  tent, 
which  now  possibly  we  may  avoid,  it  is  more  than  possible  that  forcible 
dilatation  might  suffer  by  comparison;  clearly,  it  might  be  well  to  give 
the  latter  method  a  fair  trial  under  the  favorable  conditions  of  anti- 
sepsis and  asepsis. 

Graduated  Sounds  and  Diverging  Dilators  are  generally  the  safest 
and  most  effective  means  of  dilatation,  and  usually  should  have  the 
preference. 

One  may  combine  the  principle  of  graduated  sounds  in  the  use  of 
diverging  dilators.  This  requires  a  series  of  dilators  of  graduated  sizes. 
The  small  instrument  is  inserted  first,  and  the  blades  spread;  then  the 
dilator  next  larger  is  used  in  the  same  manner;  and  so  on  through  the 
series.  Before  spreading  the  blades  each  instrument  acts  as  a  graduated 
sound;  as  the  blades  diverge  they  act  on  the  principle  of  the  glove- 
stretcher.  At  least  four  dilators  are  required :  two  of  the  Palmer,  and 
two  of  the  Wathen  variety. 

A  small  light  dilator  as  a  means  of  complete  dilatation  has  two  dis- 
advantages: first,  the  light  blades  may  bend  and  fail  to  stretch  the 
canal  beyond  a  limited  degree;  second,  if  they  do  not  spring  or  bend, 
they  are  apt  to  imbed  themselves — that  is,  crush  their  way  into  the 
uterine  walls.  The  result  is  not  dilatation  by  stretching,  but  by  tear- 
ing. The  wound  thus  inflicted  may  be  dangerous.  This  unfortunate 
result  may  be  avoided  by  the  use  of  a  graduated  series  of  instruments. 
Graduated  Bougies. — The  uterus  may  be  dilated  by  means  of  grad- 
uated bougies.  Figure  45  shows  this  method  of  dilatation;  it  is  adapted 
particularly  to  cases  in  which  the  abdominal  walls  are  thin  and  lax, 
so  that  the  uterus  may  easily  be  fixed  by  the  hand  over  the  abdomen, 
while  one  sound  after  another  is  forced  into  the  canal  until  the  required 
dilatation  is  accomplished.  If  the  abdominal  walls  are  thick  and  tense, 
it  is  necessary  to  use  Sims'  or  Simon's  speculum,  and  during  dilatation 
to  fix  the  cervix  with  the  vulsella  forceps,  but  in  such  cases  the  forceps 
are  apt  to  tear  out,  and  therefore  the  diverging  instruments  are 
preferable. 

Diverging  Instruments. — Innumerable  instruments  have  been  devised 
with  blades  which  diverge  and  dilate  the  uterus  when  the  handles  are 
pressed  or  screwed  together.  Wathen's  dilator.  Figure  47,  B,  is  the 
most  serviceable.     These  dilators  are  generally  too  heavy  to  be  inserted 


MIXOh'  ()/'Eh'AT/()\S 


115 


until  the  way  luis  been  opened  by  a  lijjhter  instrument,  like  Palmer's, 
Fiijure  47.  J,  or  by  the  smaller  j^raduated  sounds.  It  is  important 
that  all  instruments  for  powerful  dilatation  be  supplied  with  the 
thumb-screw  for  screwing  the  handles  toj^ether.  If  the  handles  are 
compressed  with  the  hand,  rupture  of  the  uterus  is  apt  to  occur.  The 
smaller  dilator  of  Palmer  does  not  require  the  screw. 


FiuiKE  47 


Forcible  dilatation  of  the  uterus:  A,  Palmer's  dilator  in  use;  B,  Wathen's  dilator,  to  be  used  for 
continuing  the  operation:  C.  anal  dilator  sometimes  useful  for  extreme  dilatation,  especially  in  cases 
of  abortion.     About  one-third  natural  size. 


Extent  of  Dilatation. — Goodell  was  foremost  among  the  advocates 
of  forcible  dilatation.  In  a  large  experience  with  extreme  dilatation 
under  ether  he  had  no  fatal  result  and  no  serious  inflammatory  dis- 
turbance. He  carried  the  dilatation  to  three-fourths  of  an  inch  in  the 
thin-walled,  unyielding  infantile  uterus,  and  to  one  and  one-quarter 
inches  in  ordinary  cases.    In  case  of  a  rigid,  unyielding,  or  thin-walled 


110  GENERAL  PRINCIPLES 

uterus,  which  might  tear  from  rapid  expansion  of  the  dilating  blades, 
it  is  permissible  with  rigid  aseptic  care  to  begin  dilatation  with  a 
sponge-  or  turpelo-tent,  the  softening  influence  of  which  prepares  the 
canal  for  more  easy  and  thorough  dilatation  by  the  forcible  method. 

The  Dangers  of  Forcible  Dilatation  are  from  traumatism  and  sepsis. 
There  may  be  extensive  rupture  from  overdistention  by  rapid  dilata- 
tion of  a  rigid  uterus,  and  dangerous  hemorrhage,  peritonitis,  and 
death  may  result.  A  uterus  ruptured  by  dilatation  should  be  packed 
and  drained  by  aseptic  gauze.  An  abdominal  or  vaginal  section  may 
be  necessary  to  control  hemorrhage. 

It  would  be  a  mistake  to  suppose  that  antisepsis  deprives  dilatation 
by  any  method  of  all  its  perils.  All  manipulations  of  this  class  are 
dangerous,  and  not  to  be  employed  unless  the  indication  is  quite  clear. 
Existing  pelvic  inflammation,  acute  or  chronic,  is  a  serious  contra- 
indication. Indeed,  the  history  of  a  majority  of  fatal  cases  includes 
previous  cellulitis,  peritonitis,  or  metritis.  Dilatation,  how^ever  slight 
by  any  method,  should  be  regarded  as  a  surgical  operation,  should 
always  be  done  at  the  patient's  house  or  a  hospital,  never  at  the  office, 
and  should  be  followed  by  rest  in  bed  for  a  time  varying  from  one  to 
seven  days.  Forcible  dilatation,  either  by  sounds  or  by  diverging 
instruments,  except  when  the  dilatation  is  to  be  slight,  requires  an 
anaesthetic.  Tenderness  and  other  signs  of  inflammation  about  the 
uterus  contraindicate  the  operation. 

If,  in  performing  forcible  dilatation  of  a  rigid  cervix,  the  force  re- 
quired suddenly  becomes  less,  the  operator  should  cease  dilating  at 
once,  for  the  lessened  resistance  usually  indicates  beginning  rupture. 

Technique  of  Forcible  Dilatation. — 1.  Disinfect  the  vagina  and  vulva. 
2.  Expose  the  cervix  by  a  Sims  or  a  Simon  speculum.  3.  Grasp  the  cervix 
flrmly  in  the  teeth  of  two  vulsellum  forceps.  Figure  47.  4.  Introduce 
the  successive  dilators  and  slowly  screw  the  blades  apart.  5.  Wash 
out  the  uterine  cavity  with  sterilized  water  from  a  fountain-syringe 
through  a  rubber  tube  and  cannula.  The  ordinary  glass  female  cath- 
eter is  a  good  cannula.  The  dilatation  should  be  sufficient  to  give  a  free 
return  flow  by  the  side  of  a  single  cannula.  During  the  w^ashing-out 
it  is  well  to  remove  and  reintroduce  the  cannula  every  two  or  three 
seconds  alternately  to  prevent  injection  of  a  possibly  patulous  Fallopian 
tube. 

Incision  of  any  portion  of  the  uterine  canal  may  be  required  in 
order  to  render  the  endometrium  accessible  for  instrumental  or  manual 
interference.  But  incision  is  especially  applicable  to  the  lower  part 
of  the  cervical  canal  and  to  the  external  os,  and  is  performed  for  con- 
genital or  acquired  stenosis.  Its  object  is  to  insure  the  free  outflow, 
not  only  of  menstrual  fluid,  but  also  of  the  uterine  mucus,  which,  if 
retained,  becomes  offensive,  irritates  the  uterine  mucosa,  and  causes 
hypersecretion.  Oftentimes  the  uterine  secretions  are  so  impeded  in 
their  passage  through  the  strictured  os  internum  or  externum  that 
they  accumulate,  distend  the  uterine  cavity,  and  are  thrown  off  at 
irregular  intervals  with  expulsive  pains  simulating  labor-pains.     This 


MINOR  OI'lih'A'I'loXS 


117 


explains  ('(Ttaiii  cases  in  wliidi   tlu-rc  is  a  rccnrrcncc  in  the  intcrincn- 
strnal  period  of  all  the  painfnl  pliciionicna  of  ol)strncti\('  (IxsnicnorrJKra. 


FiounE  48 


Incision  of  the  cervix  uteri  with  straight  scissors;  the  cervix  is  steadied  by  a  vulsella  forceps. 


Figure  49 


Examination  of  the  dilated  uterus  by  conjoined  digital  touch.  Two  vulsella  in  place  of  one 
will  be  found  advantageous,  inasmuch  as  they  are  less  likely  to  tear  out  and  unnecessarily  injure  the 
cervix. 


118 


GENERAL   PRINCIPLES 


Shroeder's  Method. — Shroeder,  in  certain  cases,  especially  of  intra- 
uterine polypi  incises  the  cervix  bilaterally,  seizes  the  posterior  lip 
with  a  vulsellum  forceps,  and,  with  his  finger  as  a  dilator,  works  his 
way  to  the  uterine  cavity.  The  uterus,  dilated  in  this  way  and  well 
drawn  down,  is  very  accessible.  Since  the  lateral  incisions  extend  into 
a  neighborhood  that  is  very  vascular  and  liable  to  infection,  the  safety 
of  the  operation  must  depend  upon  thorough  asepsis.  In  a  rigid  uterus, 
moreover,  it  is  often  impracticable  to  incise  and  dilate  according  to  the 
method  of  Shroeder. 

The  Author's  Method  of  rendering  the  entire  uterine  cavity  and  the 
uterine  walls  accessible  for  surgical  operations,  such  as  the  removal 
of  myomata  through  the  vagina  by  free  median  incision  of  the  anterior 
uterine  wall,  is  illustrated  and  described  under  the  Surgical  Treatment 
of  Myomata. 

Figure  50 


A 


Uterus  perforated  by  a  tupelo-tent.    Figure  to  left  shows  size  of  tent  before  and  after  expansion. 


Curettage 

The  diagnostic  significance  of  the  curette  has  been  given  in  Chapter 
III.  The  therapeutic  purpose  is  the  removal  of  diseased  tissue  or  foreign 
bodies  from  the  interior  of  the  uterus.  The  symptomatic  indications 
are  usually  hemorrhage,  uterine  discharges,  or  infection  due  to  some 
intra-uterine  cause.  The  instrument  was  first  used  in  184-3  by  Recamier; 
it  has  passed  through  numerous  modifications,  and  on  account  of  the 
disastrous  results  that  have  followed  the  use  of  it — perforation  of  the 
uterus,  metritis,  salpingitis,  cellulitis,  peritonitis — it  has  received  at 
times  the  severest  censure,  not  wholly  undeserved. 

The  dull  curette,  shown  in  Figure  51,  is  made  of  flexible  copper 
wire.     The  loop  has   slightly  flattened   but   not   cutting  edges;   the 


MINOR  OPERATIONS 


119 


malleable  sluink  may  he  bent  like  a  probe  to  conform  to  the  direction  of 
the  uterine  canal.  Whatever  the  force  applied,  it  is  not  likely  to  injure 
the  sound  tissue,  althou<;h  it  will  remove  loose  foreign  bodies,  such 
as  the  secundines  of  abortion. 


Figure  51 


TECHNIQUE 

OF      CURETTAGE 


Technique  of   curettage;   varieties  of  curettes;  placental  forceps.     One-third   natural  size. 


The  sharp  curette,  shown  in  Figure  51.  is  designed  to  remove  such 
di.seased  tissues  as  are  connected  more  intimately  with  the  uterus;  for 
example,  an  infected  endometrium  or  a  malignant  growth.  The  loop  is 
of  steel,  and  has  a  sharp  cutting-edge.  The  shank  is  of  flexible  copper, 
and  may  be  bent  to  conform  to  the  direction  of  the  uterine  canal.  The 
following  is  a  summary  of  the  indications  for  the  use  of  the  curette: 


120  GENERAL  PRINCIPLES 

I.  For  diagnosis  of — 

a.  New  growths  of  the  uterus — fibroids,  carcinoma,  sarcoma, 

deciduoma  mahgnum. 
h.  Inflammatory  products — endometritis, 
c.  Retained  products  of  conception — placenta,  foetus,  hydatid 

mole,  fleshy  mole. 

II.  For  therapeutic  purposes  in  cases  of — 

a.  Endometritis. 
h.  Mucous  polypi. 

c.  Inoperable  malignant  growths. 

d.  Hemorrhage  in  inoperable  fibroids. 

e.  Foreign  bodies,  such  as  secundines  of  abortion. 
The  dangers  of  the  curette  are  in  causing — 

1.  Septic  infection. 

2.  Perforation  of  the  uterus. 

3.  Hemorrhage  in  cases  of  malignancy. 

4.  Hemorrhage  and  abortion  in  cases  of  unsuspected  pregnancy. 

5.  Permanent  destruction  of  the  endometrium  by  scraping  too 

much. 
Technique  of   Curettage. — The  steps  of   curettage   are   these   (see 
Chapter  XVII.) : 

1.  Dilate  through  a  speculum  sufficiently  for  the  easy  admission  of 
the  curette. 

2.  Steady  the  cervix  with  the  vulsellum  forceps  and  introduce  the 
curette. 

3.  Should  the  object  be  to  remove  some  foreign  body,  the  dull 
curette  will  accomplish  this  readily  if  used  like  a  rake.  Little  force 
is  required.  The  sensation  imparted  to  the  fingers  will  show  whether 
all  the  foreign  substance  has  been  removed — i.  e.,  whether  the  loop 
glides  over  a  smooth  surface. 

4.  If  the  object  be  to  remove  diseased  tissue,  the  sharp  curette 
should  be  used  w^ith  a  back-and-forth  scraping  motion  round  and  round 
the  endometrium.  The  operator  will  know  when  the  tissue  has  been 
removed  sufficiently:  first,  by  the  fact  that  no  more  comes  away; 
second,  by  the  sensation  which  the  curette  imparts  to  the  fingers,  of 
a  hard-resisting,  more  or  less  healthy,  intra-uterine  surface. 

5.  The  diseased  tissue  having  been  scraped  away,  the  endometrium 
should  be  washed  out  with  sterilized  water. 

6.  If  it  is  desirable  to  apply  a  medicinal  substance,  such,  for  example, 
as  a  saturated  solution  of  iodine  crystals  in  pure  carbolic  acid,  this  may 
be  done  by  means  of  an  applicator  or  a  fine  dressing-forceps  wound 
with  absorbent  cotton.  Before  making  the  application,  pack  absorbent 
cotton  under  the  cervix,  to  absorb  any  fluid  which  otherwise  might 
run  out  and  irritate  the  vagina. 

7.  The  after-treatment  is  rest  in  bed  for  a  week,  with  \'aginal  douches 
twice  daily  of  some  disinfectant  such  as  0.5  per  cent,  solution  of  lysol 
in  sterilized  water. 


CHAPTER   VI 

MAJOR  OPERATIONS 

This  cliaptor  is  a  general  consitleration  of  those  procedures  which 
are  common  to  the  opening  of  the  peritoneal  caAity.  Peritoneal  sec- 
tion may  be  made  through  the  abdominal  walls  or  through  the  ^•agina; 
hence  the  subject   is  divided  into — 

1.  Abdominal  section.  , 

2.  Vaginal  section. 


1.    ABDOMINAL    SECTION 

Operating-tables. — The  table  already  described  for  examination  and 
for  vaginal  operations  will  suffice  for  abdominal  section,  if  lengthened 
so  that  the  patient  may  lie  upon  it  at  full  length.  For  this  purpose  a 
short  table  may  be  supplanted  by  a  stand  or  by  another  shorter  table. 

Figure   52 


Trendelenburg  position:   table  improvised. 

The  Trendelenburg  Position.— A  favorite  table  for  hospital  use, 
and  especially  for  abdominal  section,  is  that  of  Trendelenburg  or  some 
modification  thereof.  The  top  of  the  table  may,  at  any  time  during 
an  operation,  be  adjusted  readily  to  any  desired  angle,  and  by  this 

(121) 


122 


GENERAL  PRINCIPLES 


means  the  hips  may  be  elevated  so  as  to  cause  the  intestine  to  gravi- 
tate away  from  the  pelvis  toward  the  diaphragm.  The  surgeon  may 
then  gain,  in  favorable  cases,  an  almost  unobstructed  view  of  the  pelvic 
basin  and  may  work  deep  in  the  pelvic  cavity  unimpeded  by  the 
distended  intestine.  It  is  even  maintained  by  advocates  of  this  posi- 
tion that  in  these  favorable  cases  the  operation  may  be  proceeded  with 
as  readily  as  if  it  were  on  the  external  surface.  Extravagant  claims 
are  made  that  this  position  makes  pelvic  surgery  easy,  so  that  an 
indifferent  operator  may  undertake  it  safely.  The  table  is  useful 
during  anaesthesia  when  the  pulse  and  respiration  fail  and  it  becomes 
desirable  to  elevate  the  lower  extremities  and  lower  the  head. 


Figure  53 


Ordinarj'  gauze  sponges  saturated  with  hot  normal  salt  solution  held  by  a  retractor  to  keep 
the  intestines  out  of  the  operator's  way. 


The  advantages  of  this  position,  although  admitted,  should  not  be 
overestimated.  Besides  the  fact  that  in  many  cases  the  field  of  opera- 
tion is  not  rendered  more  accessible,  the  position  has  several  disad- 
vantages: first,  infectious  fluids  which  escape  during  the  operation  are 
certain  to  gravitate  toward  the  diaphragm,  and  may  infect  the  general 
peritoneum;  second,  the  abdominal  muscles  often  are  made  more  rigid. 
The  Trendelenburg  position  does  not  overcome,  but  rather  lessens,  a  few 
—only  a  few — of  the  difficulties  and  dangers  of  abdominal  surgery. 


MAJOR  orERATlOXS  123 

With  the  patiiMit  on  an  onhnary  tal)li',  hir<;e  <,Mii/,t'  pads  may  be  used 
in  such  a  way  as  to  keep  the  intestine  out  of  the  way,  and  tliereby 
to  render  aee(>ssihle  the  deeper  parts  of  the  jx^his. 

Improvised  Substitute  for  the  Trendelenburg  Table.  The  end  of  a 
common  tahle  may  be  raised  on  a  l)I()ck  or  chair  sc^  as  to  ^ivc  it  the 
required  shuit.  The  patient  then,  witli  the  legs  hanging  over  tlie  f(jot 
of  the  tal)le,  may  readily  be  adjusted  to  the  desired  angle  without 
recourse  to  tlie  mow  or  h-ss  complicated  Trendelen})urg  table. 

The  Preparatory  Treatment. — The  necessary  antiseptic  procedures 
to  an  aseptic  result  have  been  set  forth  in  Chapter  II. 

It  is  furthermore  important,  before  beginning  a  grave  operation, 
that  the  various  organs  of  elimination  be  sufficiently  active,  so  that 
the  danger  of  auto-intoxication  from  the  retention  of  waste-products 
may  be  reduced  to  the  minimum.  The  demand  made  upon  the  patient 
by  the  operation  itself  reduces  the  eliminating  capacity  of  these  organs, 
sometimes  to  the  point  of  danger;  hence  the  imperative  necessity  of 
lightening  the  burden.  Careful  examination  of  the  kidneys  and  heart 
may  lead  to  essential  preparatory  treatment  of  these  organs. 

The  Incision. — To  open  the  abdomen  only  a  few  instruments  are 
required;  in  fact,  it  may  be  laid  down  as  a  general  proposition  that 
the  most  skilful  surgeons  operate  with  the  fewest  instruments.  A 
scalpel,  a  few  strong  haemostatic  forceps,  long  and  short,  and  a  pair 
of  strong  straight-bladed  scissors  are  quite  sufficient.  Twelve  short 
and  six  long  haemostatic  forceps  will  suffice  for  any  operation.  Sir 
Spencer  Wells  and  others  have  reported  cases  in  which,  after  the 
operation,  hismostatic  forceps  were  found  post  mortem  in  the  peri- 
toneal cavity.  In  order  to  avoid  this,  one  should  operate  always  with 
the  same  number  of  forceps,  or  at  least  carefully  count  and  record 
the  number  before  the  operation  is  begun,  and  before  closure  of  the 
wound.  Unless  the  operator  is  certain  of  his  assistant,  he  will  do  well 
to  count  them  himself.  The  incision  for  gynecological  exploration 
or  operation  is  usually  in  the  median  line  near  the  pubes.  I  prefer  the 
incision  between  the  inner  and  middle  third  of  the  right  rectus  muscle; 
this  incision  gives  ready  access  to  the  pelvic  ca\-ity,  the  appendix 
vermiformis  and,  if  enlarged  upward,  to  the  gall-bladder,  all  of  which 
should  usually  be  examined  as  a  routine  in  every  operation. 

Exploration. — Every  abdominal  section  should  begin  as  an  explora- 
tory incision,  which  at  first  should  be  made  long  enough  only  to  admit 
the  index  finger  for  examination.  If  it  is  necessary  to  introduce  the 
hand,  the  incision  may  be  extended  in  either  direction.  The  operator 
now  decides  whether  he  will  close  the  wound  after  the  simple  diagnostic 
exploration  or  proceed  to  a  complete  operation.  'Sir.  Tait,  in  urging 
the  exploratory  incision  as  the  first  step  of  an  abdominal  operation, 
once  wisely  said:  "/f  is  always  easy  to  turn  an  exploratory  incision 
into  an  operation,  but  often  quite  impossible  to  turn  an  incomplete  opera- 
tion into  an  exploratory  incision." 

The  Median  Incision  through  the  Linea  Alba  does  not  expose  nor  wound 
the  recti  muscles.    If,  however,  the  linea  alba  has  been  displaced  by  a 


124 


GENERAL  PRINCIPLES 


tumor  or  by  other  causes  and  is  not  readily  found,  one  may  properly 
ignore  it,  cut  directly  through  the  upper  fascial  sheath,  separate  the 
fibers  of  the  muscle  longitudinally,  and  then  divide  the  structures 
beneath  until  the  cavity  is  reached.  When  cutting  down  upon  a  tumor, 
one  often  reaches  the  linea  alba  with  the  first  stroke  of  the  scalpel, 
and  the  subperitoneal  fat  with  the  second.  The  fat  is  then  separated 
by  the  finger  and  handle  of  the  scalpel,  and  the  peritoneal  membrane 
exposed.  Bleeding  points  usually  are  secured  by  pressure-forceps; 
ligatures  seldom  are  required.  The  peritoneum  is  then  superficially 
caught  by  two  small  pressure-forceps.  The  operator's  left  hand  retains 
one,  and  that  of  the  assistant  the  other.  The  peritoneum  is  usually 
so  translucent  that  the  viscera  just  beneath  can  be  seen  as  it  glides 
over  them;  it  is  now  lifted  from  the  viscera  by  the  pressure-forceps, 
and  by  a  single  stroke  of  the  scalpel  divided  between  them.  The 
grooved  director  formerly  in  use  is  rather  a  hindrance  than  a  help. 


Figure  54 


Abdominal  incision:     lower  hand  holding  knife  correctly:  upper  hand  holding  knife  incorrectly. 


In  grasping  the  peritoneum  in  the  two  forceps  for  incision,  one  should 
be  careful  not  to  include  a  bit  of  intestinal  wall.  The  writer  once  in 
this  way  opened  the  intestine;  immediate  suture,  however,  resulted 
in  prompt  union,  and  no  permanent  harm  was  done.  Sometimes  the 
intestine  is  adherent  to  the  parietal  peritoneum  and  is  very  liable  to  be 
cut  unless  the  incision  is  made  slowly  and  with  great  care.  Sometimes 
one  may  avoid  cutting  through  the  bladder-wall  by  recognizing  in  time 
its  greater  vascularity  and  the  numerous  little  bleeding-points.  If  the  in- 
testines or  bladder  are  adherent  and  unrecognizable,  this  fact  will  be 
apparent  by  the  failure  of  the  operator  to  see  the  viscera  through  the 
translucent  peritoneum,  or  by  the  fact  that  the  peritoneum  does  not, 
as  in  an  ordinary  case,  glide  over  them.  It  is  then  better  to  prolong  the 
incision  upward  or  downward  and  enter  the  abdomen  above  or  below. 


MAJOR  OI'EliATIONS  125 

Tlir  adluTont  \'i.sc(T;i  iii;iy  then  l»c  (Ictachcd  and  tlic  incision  coiii- 
])I('t('d  to  its  ori^dnal  j)oiiit.  1  )('lil)cration,  care,  and  jnd^incnf  will 
cnal)lc  the  beginner  usuallv  to  find  his  way  safely  to  the  abdominal 
cavity. 

"^rhe  ea\ity  l)ein^'  open,  the  incision  may  he  li'nfi,thened  as  desired 
hy  the  seissors  on  the  inserted  in(lex-fin<,a'r  as  a  f:;ui(le.  The  len<rth 
of  the  incision  will  vary  with  the  re(|nirements  of  the  case  and  tiie 
dexterity  of  the  operator;  other  thinf;s  heiiifj;  e(|iial,  the  shorter  the 
ineision  the  less  the  danger.  Sufficient  room,  however,  should  be 
given  for  effective  work.  The  added  risk  of  a  hunger  incision  f)y  com- 
parison with  the  added  safety  of  an  unimpeded  operation  is  insig- 
nificant. The  i)ressure-force])s  may  now  be  remo^•ed  from  the  bleeding- 
points;  if  at  any  point  tiie  bleeding  continues,  it  may  be  controlled  by 
torsion  or  l)y  fine  catgut  ligature. 

Before  in\ading  the  abdominal  cavity  for  purposes  of  examination 
or  operation,  one  should  seize  the  margins  of  the  jjeritoneum  by  two 
or  three  forceps  on  either  side,  and  draw  it  out  through  the  wound 
toward  its  cutaneous  edges  so  as  to  make  it  cover  the  cut  surfaces. 
The  wound  thereby  is  protected  and  the  peritoneum  is  in  no  danger 
of  being  stripped  off  from  its  adjacent  tissues  as  it  might  otherwise 
be  during  the  subsequent  manipulations. 

Adhesions. — The  conditions  which  give  rise  to  adhesions  usually  also 
cause  more  or  less  thickening  of  the  peritoneum.  Sometimes  the 
parietal  peritoneum  is  so  thick  as  to  be  unrecognizable.  The  operator 
may  be  uncertain  w^hether  he  has  cut  through  the  peritoneum,  and  this 
uncertainty  may  be  increased  by  the  presence  of  adherent  intestine. 
Large  areas  of  peritoneum  have  been  detached  from  the  adjacent 
abdominal  wall  under  the  impression  that  the  peritoneum  had  been 
divided,  and  that  intraperitoneal  adhesions  w^ere  being  separated. 
Experience  and  sense  are  the  only  guides.  There  are  no  safe  rules. 
Adhesions  usually  are  separated  by  means  of  the  finger,  the  hand,  or 
the  sponge.  If  great  care  is  not  used  in  separating  intestinal  adhesions, 
one  or  more  coats  of  the  bow^el  w^all  may  be  stripped  off  with  the  adherent 
tissues;  this  might  result  in  sloughing  and  a  consequent  fecal  fistula. 
Such  traumatism  should  be  repaired  promptly  by  draw'ing  together 
the  peritoneal  margins  wath  fine  chromic  catgut  or  silk  sutures.  The 
sponge,  as  used  by  the  late  Thomas  Keith,  is  a  most  useful  means 
of  separating  intestinal  or  omental  adhesions.  By  firm  and  gentle 
sponge  pressure  against  the  adherent  bowel  at  the  point  of  attachment, 
one  literally  may  sponge  it  away  from  the  tumor.  It  is  surprising  to 
note  the  facility  with  which  rather  firm  adhesions  may  thus  be  broken. 
In  breaking  the  adhesions  in  this  way  the  surgeon  avoids  stripping 
off  one  or  more  coats  of  the  bowel.  On  the  contrary,  the  peritoneal 
covering  of  the  tumor  is  apt  to  remain  on  the  bowel.  The  sponge 
method  is  more  gentle,  more  eftective,  and  less  productive  of  shock 
than  the  usual  method  of  tearing  wdth  the  finger.  Adhesions  too 
strong  for  the  sponge  or  finger  have  to  be  cut. 


126 


GENERAL   PRINCIPLES 
Figure  55. 


Abdominal  incision,  cutting  through  peritoneum.  Peritoneum  held  up  away  from  abdom- 
inal viscera  by  pressure-forceps.  Forceps  on  left  held  by  left  hand  of  assistant ;  forceps  on 
right  held  by  left  hand  of  operator. 

Figure  56. 


Enlarging  abdominal  incision.    Forceps  shown  in  Iigure  55  are  lying  one  on  either  side  of 
wound  with  everted  margins  of  peritoneum  in  their  grasp. 


MAJOR  Ol'ERATlONS 


127 


Intraperitoneal  Haemostasis.  ll('in()ri'li;i<;('  (liiriii<;-  an  operation  is 
treated  on  ,t;;cMUTal  surjiical  jjrincipk's  of  forciprcssure,  li<i;ature,  torsion, 
sponge-pressure,  styj)ti(s,  or  eauterization. 

Pressure-forceps  placed  on  small  bleeding-points  as  tlie  ojX'ration 
proceeds,  and  left  there  a  few  minutes,  usually  will  suffice.  If  the 
hemorrhage  continues,  each  point  may  be  secured  by  torsion  or  by  a 
fine  catgut  ligature;  or  se\eral  points,  by  a  basting  process,  may  be 
included  in  a  ligature.  Troublesome 
oozing,  deep  in  the  pelvic  wall,  often  sub-  ■ "  '  i"  '>" 

sides  on  long-continued  sponge-pressure. 
The  sponge  should  be  wriuig  out  in  very 
hot  water,  antl  very  firmly  packed  against 
the  bleeding  surface,  and  left  there  for 
several  minutes.  Iron,  tannin,  and  alum, 
since  they  are  liable  to  leave  masses  of 
coagulated  blood  which  may  decompose 
in  the  pelvis,  are  objectionable.  A  steri- 
lized 10  per  cent,  solution  of  antipyrine 
applied  with  the  sponge  is  a  safe  and 
often  effective  styptic. 

The  actual  cautery  in  the  abdominal 
cavity  should  be  used  if  at  all  with  great 
caution  for  fear  of  injuring  some  neigh- 
boring viscus.  Its  use  is  permissible  if 
the  region  to  be  treated  can  be  drawn 
through  the  abdominal  incision  and  the 
application  be  made  under  direct  inspec- 
tion. It  is  of  value  in  cases  of  paren- 
chymatous oozing  which  is  not  controlled 
by  suturing,  and  in  the  appendix  stump, 
or  infected  Fallopian  tube. 

Catgut  versus  Silk  for  Ligatures. — Haemo- 
stasis is  secured  best  by  catgut — see 
Sterilization  of  Catgut,  Chapter  II.  Cat- 
gut is  preferable  to  silk  because  in  case 
of  localized  infection  around  the  ligature 
the  non-absorbable  silk  remains  as  a 
foreign  body  and  is  apt  to  perpetuate  a 
suppurative  process.  This  process,  if  the 
patient  survives,  may  form  a  sinus  leading 

from  the  ligature  to  the  external  surface,  usually  through  some  point  in 
the  abdominal  wound.  Such  a  sinus  may  continue  to  suppurate  for 
weeks,  months,  or  years,  until  the  ligature  is  cast  out  or  manually 
removed.  Catgut  sutures  and  ligatures  disappear  by  absorption  in  a 
few  days  or  weeks,  and  give  no  further  trouble;  if  of  good  quality 
and  properly  disinfected,  they  are  perfectly  reliable  and  safe. 

Closure  of  the  Wound. — The  ordinary  method  by  through-and- 
through   interrupted   sutures,   including   the   entire   thickness   of   the 


Facial  sheaths  of  rectus  muscle  on  one 
side,  being  split  by  scissors. 


Figure  58. 


Figure  59. 


SUBCUTANEOUS 


Figure  58.— Showing  deep  tier  of  buried  running  catgiit  suture,  which  unites  the  peri- 
toneum. The  suture  may  also  embrace  the  posterior  fascia  and  muscle.  Observe  that  the 
suture  was  introduced  at  A  and  is  there  being  held  in  place  by  means  of  forceps  :  It  first  closes 
peritoneum  from  the  lower  to  the  upjier  end  of  the  incision  ;  it  then  returns  to  the  lower  end, 
closing  the  anterior  fascia,  as  shown  in  Figures  59  and  60,  and  finally  emerges  and  is  tied  at 
point  of  original  entrance— point  A. 

FiGrRE'og. — Fascial  margins  of  wound  closed  by  second  tier  of  buried  running  suture.  The 
recti  muscles  are  now  being  covered  in  by  the  united  fascia. 


Figure  60. 


Figure  61. 


Figure  60.— Union  of  fascial  margins  complete  ;  suture  is  being  passed  out  by  needle  to 
point  of  entrance  A  preparatorv  to  tving.    Suture  is  shown  as  tied  at  A  in  figure  61. 

Figure  61.— The  running  suture,  which  has  closed  peritoneum,  recti  muscles,  and  fascia  in 
two  tiers  has  been  tied  at  point  of  entrance  and  exit  A.  A  final  suture  first  tied  at  lower  end 
of  wound  is  being  deeply  introduced  to  close  subcutaneous  fat  and  skin,  observe  that  there  are 
no  buried  knots  to  cause  suppuration  and  that  the  deep,  wide  external  suture  closes  the  subcu- 
taneous fat  securelv  and  prevents  dead  spaces.  Moreover,  its  relations  with  the  margins  of  the 
wound  are  so  remote  that  it  causes  little  irritation.  Above  all,  it  should  not  be  tightly  drawn- 
just  tightly  enough  to  hold  the  cut  margins  in  apposition  ;  this  suture  should  be  iodized  gut. 
128 


MAJOR  OPERATIONS  12!J 

abdominal  wall,  and  t\iii<i:  upon  the  skin,  should  he  abandoned,  and 
the  inctliod  of  hurled  chromic  catirut  suture  should  he  substituted. 

The  Buried  Catgut  Suture  Throughout.'—  Number  2  eatgut  sufficiently 
chromieized  to  resist  absorption  for  six  weeks  should  be  used.  The 
teehniciue  is  as  follows:  In  order  to  ^^We  broader  surfaces  for  union, 
and  couseciuently  <jreater  streuiith,  the  ineision  is  made  into  the  sheath 
of  the  reetus  muscle  on  that  side  on  which  the  muscle  was  not  exposed 
by  the  abdominal  ineision.  If,  perchance,  the  abdominal  inci.sion 
was  made  directly  throujjh  the  linea  alba,  without  exposing  a  rectus 
muscle,  the  sheath  is  deliberately  to  be  divided  on  either  side  with  the 
scissors,  as  shown  in  Figure  57.  This  gives  double  fascia  edges  and 
broad  muscular  surfaces  for  union.  The  purpose  of  the  buried  suture 
is  to  approximate  the  muscular  and  fascial  layers  of  the  wound,  so 
as  to  insure  apposition  of  homologous  parts,  and  to  retain  them  in 
approximation  long  enough  to  secure  firm  union. 

The  running  suture  is  preferable  to  the  interrupted,  first,  because 
it  brings  corresponding  structures  more  accurately  and  more  quickly 
together;  second,  because,  in  the  method  described,  it  gives  no  buried 
knots.  The  second  advantage  is  considerable,  for  the  bulky  catgut 
knot  tends  to  cause  suppuration  or  failure  of  union. 

Closure  of  the  abdominal  wound  by  buried  catgut  sutures  is  made 
as  follows: 

The  needle  is  introduced  at  the  lower  extremity  of  the  wound  of 
the  right  side  (Figure  58,  A),  and  at  the  first  thrust  is  carried  through 
skin,  fat,  anterior  fascia,  muscle,  and  peritoneum.  The  suture  then  is 
continued  as  a  running  suture  the  length  of  the  wound,  and  unites  the 
peritoneum.  The  posterior  fascia  and  muscle  may  be  united  by  this 
suture  at  the  same  time  with  the  peritoneum.  The  suture  then  is  carried 
back  to  the  starting-point,  wdiipping  together  the  outer  fragments 
of  the  divided  anterior  fascia,  thus  bringing  the  recti  muscles  firmly 
together.  It  finally  emerges  at  the  point  of  entrance.  A,  where  it  was 
introduced  first,  and  is  tied.    Figures  60  and  61. 

In  connection  with  the  subject  of  suture  for  abdominal  incision  the 
reader  is  referred  to  the  Surgical  Treatment  of  Enteroptosis  and 
Umbilical  Hernia. 

The  splitting  of  the  sheaths  of  the  recti  muscles  is  essential  in  cases 
of  relaxed  abdominal  walls,  especially  when  there  are  enteroptosis 
and  pendulous  abdomen;  this  method  insures  a  good  result  so  far  as 
the  correction  of  the  side-to-side  relaxation  is  concerned,  but  does 
not  always  overcome  the  longitudinal  relaxation.  Figure  62  shows 
a  method  by  which  the  upper  end  of  the  wound  is  closed  in  a  line  at 
right  angles  to  the  incision  so  as  to  hold  up  the  relaxed  pendulous 
abdomen.  The  transverse  part  of  the  closure  may  be  at  the  upper 
or  lower  end  or  auA'where  in  the  continuity  of  the  wound  or  both  at 
the  upper  and  lower  ends.    An  ordinary  continuous  chromic  or  iodized 


1  Modified  from  George  M.  Edebohls.    American  Gynecological  and  Obstetrical  Journal,  May,  1896, 
consulted. 


130 


GENERAL  PRINCIPLES 


catgut  suture  is  sufficient.  For  the  cutaneous  part  of  the  wound 
Claudius'  iodized  gut  is  preferred. 

Stitch-abscesses  are  very  Hable  to  occur  unless  the  following  pre- 
cautions are  observed: 

1.  The  abdomen  should  be  opened  with  a  sharp  scalpel,  which  will 
make  a  clean  cut,  not  a  ragged,  uneven  incision. 


Figure  62 


Closing  the  wound  with  stay  sutures  and  Michelle  clips.  The  lower  stay  suture  already  has  been 
passed,  the  dotted  lines  showing  the  part  which  is  buried  underneath  the  surface.  One-half  of  the 
upper  suture  has  been  passed,  the  other  half  is  being  passed. 

2.  Great  care  should  be  used  during  the  operation  not  to  bruise 
or  tear  the  wounded  surfaces. 

3.  All  bleeding  should  be  arrested  before  closure  of  the  wound. 

4.  Absolute  asepsis  should  be  secured  in  hands,  instruments,  .sponge 
sutures,  and,  above  all,  in  the  field  of  incision.    See  Chapter  II. 

5.  Sutures  never  should  be  drawn  so  tightly  as  to  strangulate  the 
parts: 

6.  Burying  of  knots  should  be  avoided  if  practicable. 

Mattress  Sutures  and  Michelle  Clips. — For  security  against  dead  spaces 
in  the  wound  which  may  accumulate  blood  or  w-ound  secretions  and  give 
rise  to  suppuration,  I  have  for  many  years  used  with  gratifying  results 
mattress  sutures  of  silkworm  gut,  as  described  in  the  accompanying 
illustrations.     For  closure  of  the  skin  margins  INIichelle  clips  will  secure 


MAJOR  UPEIiATIONS 


131 


Figure  63 


Closing  the  tround  with  stay  sutures  and  Michelle  clips.  A  roll  of  gauze  has  been  drawn  through  the 
loops  on  the  right  side,  and  a  similar  roll  is  being  drawn  through  on  the  left  side.  This  gauze  prevents 
the  sutures  when  tied  from  cutting  the  skin;  when  tied  they  approximate  the  fascial  and  adipose  por- 
tions of  the  wound. 


FiGtrnE  64 


Closing  of  the  wound  with  stay  sutures  and  Michelle  clips.    One  stay  suture  has  been  tied  and  one  is 
being  tied.     These  sutures  should  be  removed  in  about  seven  days. 


132 


GENERAL  PRINCIPLES 


very  accurate  coaptation,  give  relatively  little  discomfort  to  the  patient 
and  limit  the  chance  of  superficial  wound  infection.  The  removal  of 
these  clips  is  best  done  by  a  special  instrument,  which  may  be  obtained 
of  any  instrument-maker.     See  Figures  62  to  65. 


Figure  65 


Closinq  the  wound  with  stay  sutures  and  Michelle  clips.     Mattress  sutures  tied.     Cutaneous  margins 
of  wound  being  approximated  by  Michelle  clips.    The  margins  are  being  drawn  taut  by  means  of  ten-  ■ 
acula  at  each   end  to  facilitate  closure.      A   clip  is  being  placed  by  forceps.      The  clips  should  be 
removed  in  about  seven  days. 


In  the  approximation  of  the  cutaneous  edges  of  the  wound  for  which 
sutures  ordinarily  are  used,  I  cannot  too  strongly  urge  th«  use  of  these 
clips  or  clamps,  the  introduction  of  which  is  set  forth  in  Figure  65. 

Should  suppuration  in  the  wound  or  along  the  sutures  occur,  the 
sutures,  if  of  the  through-and-through  variety  and  tied  on  the  skin, 
should  be  removed  at  once.  The  buried  suture  must  be  left  in  place 
until  it  is  absorbed.  A  dressing,  wet  with  70  per  cent,  alcohol,  should 
be  maintained  continuously.  Free  drainage  by  incision  should  be 
established  if  necessary  to  drain  out  any  considerable  accumulations 
of  pus.  Immobilization  of  the  abdominal  walls  by  a  firm  bandage 
will  tend  to  prevent  separation  of  the  wound  in  case  there  should  be 
suppuration  either  in  the  superficial  or  in  the  deep  parts  of  it. 

Sponges. — In  nearly  every  extensive  abdominal  section  numerous 
sponges,  preferably  gauze  sponges,  are  packed  into  the  abdominal 
cavity,  not  only  to  absorb  blood  and  other  fluid,  but  to  control  hemor- 
rhage by  pressure,  and  to  hold  the  intestine  and  other  viscera  out  of 
the  way  of  the  operator. 


MAJOR  ()]'ER.\ri()\'S 


133 


How  to  Avoid  the  Leaving  of  Sponges  in  the  Abdomen.  It  i>  (|iiitc  iiii- 
jxtssiMf  (luriiii;  the  proj^Tcss  of  ;iii  alxloiiiiiiiil  section  tor  the  ojKTiitor 
to  keep  track  of  the  exact  iiiimher  of  si)oiii,'es  which  ma\'  he  inside  of 
the  abdomen;  hence  numerous  humihatinii',  not  to  sa\  fatal,  r(>sults 
of  closure  of  tlie  wound  and  completion  of  the  oj)eration  with  one  or 
more  sponges  remaining  in  the  peritoneal  cavity.  The  not  infrequent 
occurrence  of  this  de])Iorahle  accident,  even  at  the  hands  of  careful 
men,  is  the  writer's  excuse  for  introducing  two  personal  experiences; 
verily,  how  nuich  expi-rience  one  may  get  from  a  single  case! 

Figure  06 


In  cases  of  enteroptosis  and  pendulous  abdomen  it  may  be  necessary  not  only  to  split  tlie  sheaths 
of  the  recti  muscles,  but  also  to  remove  a  strip  of  skin  and  subcutaneous  fat  on  either  side  of  the  wound 
in  order  to  take  up  the  lateral  slack  in  the  abdominal  wall.  Not  infrequently  there  will  still  remain 
considerable  longitudinal  slack,  which  should  be  disposed  of  by  uniting  some  portion  of  the  wound 
in  a  direction  at  right  angles  to  the  line  of  incision,  as  follows: 

A.  The  peritoneal  and  fascial  margins  of  the  wound  have  been  closed  completely.  The  cutaneous 
margins  of  the  lower  two-thirds  of  the  wound  have  been  clo.sed  in  the  usual  manner.  The  upper  third 
is  being  held  slightly  apart  by  two  tenacula. 

B.  The  upper  part  of  the  wound  is  being  drawn  ^sddely  apart  by  two  tenacula  so  that  it  may  be 
closed  in  a  direction  running  at  right  angles  to  the  line  of  incision.  The  dotted  lines  indicate  that  part 
of  the  skin  and  subcutaneous  fat  are  to  be  removed,  so  that  the  wound  when  closed  may  have  a  level 
surface   all  around  it  free  from  folds.  . 

C.  The  closure  of  the  wound  is  being  completed  by  the  introduction  of  the  last  stitch.  In  this 
Figure  the  suture  is  not  subcutaneous  but  over-and-over,  although  the  subcutaneous  suture  would 
be  permissible.     The  over-and-over  stitch  is  shown  here  in  order  to  demonstrate  it. 


The  first  case  was  one  of  extensive  suppuration  of  the  uterine  appen- 
dages with  nearly  universal  old,  firm  adhesions  throughout  the  pelvis, 
and  with  the  uterus  enlarged  by  chronic  endometritis  and  metritis 
to  about  four  times  its  natural  size.  All  the  diseased  organs  were 
removed  by  abdominal  and  vaginal  section.  The  operation,  especially 
the  hysterectomy,  was  exceptionally  difficult  and  tedious.    The  broad 


134 


GENERAL   PRINCIPLES 


ligaments  were  so  short  and  thick  as  to  be  inaccessible  for  the  ligature, 
and  almost  for  the  clamps.  Each  ligament  was  so  thick  that  through 
the  vagina  it  had  to  be  clamped  in  three  parts.  The  patient  was  put 
to  bed  apparently  nearer  dead  than  alive.  The  writer's  usual  precau- 
tions had  been  taken  to  prevent  closing  the  wound  with  a  sponge  inside. 
The  sponges  had  been  brought  to  the  operation  in  sterilized  packages, 
each  containing  eight,  so  that  the  number  must  have  been  eight  or 
some  multiple  of  eight.  Only  large,  fiat  gauze  sponges  were  used. 
The  operation  was  begun  with  the  eight  sponges  of  one  package,  which 
were  counted.  Two  additional  packages  of  eight  each  were  required 
in  the  course  of  the  operation,  all  of  which  were  supposed  to  have  been 
counted  accurately  by  the  nurse  in  charge  of  them.  Just  before  the 
abdominal  sutures  were  introduced  the  nurse  was  directed  to  count 
the  sponges.  She  reported  them  "all  out."  After  the  introduction 
of  the  sutures,  and  before  they  were  tied,  she  was  told  to  count  them 
again,  and  this  count  also  made  the  number  twenty-four  and  "all  out." 
With  the  evidence  of  a  double  count,  that  there  could  be  no  sponge 
in  the  abdomen,  the  wound  was  closed. 


Figure  67 


In  some  cases  the  skin-margins  do  not  fall  closely  enough  together;  it  is  then  necessarj'  to  unite 
them  by  means  of  a  continuous  or  interrupted  suture  with  a  very  fine  long  needle,  with  sharp  point, 
threaded  with  fine  catgut. 


Three  hours  later  the  nurse  reported  that  one  of  the  gauze  sponges 
used  in  the  abdomen  could  not  be  found.  After  consultation  wdth 
two  colleagues  it  was  decided  to  assume  for  the  time  that  the  missing 
sponge  had  been  lost  outside  the  abdomen,  and  that  consequently  the 
peritoneal  cavity  was  clear. 

Convalescence  was  uninterrupted  till  the  tenth  day,  when  the  stitches 
were,  removed.  At  this  time  there  was  noticed  a  semiresonant  mass  of 
irregular  ovoid  shape,  as  large  as  a  medium-size  orange,  in  the  region 


MAJOR  OI'ERATIONS  135 

of  tilt'  riiilit  kidiu'v;  it  <,fuve  to  the  palpating  hand  the  sensation  of 
a  mass  of  jjanzc  niin<^k'(l  with  adluTcnt  intestine.  Two  colleagues 
agreed  that  it  would  be  wise  to  wait  for  develojjnients.  Sixteen  hours 
later,  at  11  p.m.,  the  mass  had  increased  in  size,  become  painful,  the 
pulse  had  risen  from  100  to  120,  and  the  temperature  from  99°  to  101°. 
There  was  slightly  increased  distension,  accompanied  by  a  tendency  to 
pronounced  nausea.  After  a  hasty  consultation,  the  family  being 
informed  of  our  suspicions  and  fears,  chloroform  was  given  and  the 
abdomen  opened  directly  over  the  mass.  The  incision  was  made  without 
the  usual  assistants,  at  midnight,  and  revealed,  not  a  sponge,  but  a 
much  enlarged  kidney  surrounded  and  covered  by  firmly  adherent 
intestine  looped  and  matted  together  in  an  irregular  mass.  In  working 
through  the  thickened,  unrecognizable,  adherent  parietal  peritoneum, 
and  between  the  layers  of  visceral  peritoneum  and  the  adherent  intes- 
tine, also  thickened  and  difficult  to  recognize,  the  intestine  was  opened 
accidentally.  The  opening  immediately  was  repaired  with  interrupted 
Lembert  sutures,  and  the  abdominal  wound  closed  without  drain. 

Three  days  later  the  contents  of  the  small  intestine,  probably  the 
upper  part  of  the  ileum,  came  through  the  abdominal  wound,  and  an 
intestinal  fistula  thereby  was  demonstrated.  During  the  following 
five  weeks  no  feces  passed  by  the  anus;  all  bowel  evacuations  came 
through  the  fistula.  The  opening  was  so  high  in  the  bowel  that  nutri- 
tion seriously  was  impaired  and  emaciation  began.  The  fear  of  a  for- 
midable operation  to  restore  the  integrity  of  the  bowel  increased  day 
by  day.  Finally,  to  the  writer's  unspeakable  relief,  in  the  sixth  week 
fecal  matter  appeared  at  the  anus.  The  fistula  began  to  contract,  and 
in  a  few  days  was  closed  completely.  The  kidney  enlargement  entirely 
subsided,  and  repeated  urinalysis  showed  no  evidence  of  functional 
impairment. 

The  prolonged  anxiety  and  distress  of  such  a  case  are  beyond  de- 
scription. They  are,  both  for  the  surgeon  and  for  the  patient,  a  life- 
shortening  experience.  The  burden  of  this  case  was  lightened,  first, 
by  the  ultimate  recovery  of  the  patient;  second,  by  the  complete  relief 
which  she  has  experienced  since  from  a  distressing  intestinal  catarrh 
which  had  made  her  a  semi-invalid  for  fifteen  years.  This  relief  is 
attributed  to  the  continuous  rest  to  which  that  portion  of  the  bowel 
below  the  injury  was  subject  while  the  fistula  was  open. 

The  second  case  was  one  of  intraligamentous  ovarian  cyst  on  each 
side,  with  double  sactosalpinx  serosa  and  universal  adhesions.  The 
sponges  were  counted  carefully  before  the  incision  was  made.  Before 
the  wound  was  closed,  the  nurse  again  counted  them  and  reported  one 
missing.  After  a  search  of  fifteen  minutes  among  the  abdominal  viscera, 
the  nurse  in  the  meantime  looking  for  the  sponge  outside,  it  could 
not  be  found.  In  the  hope  of  finding  the  sponge,  the  incision,  pre- 
viously short,  was  extended  to  the  navel,  preparatory  to  turning  out 
the  intestines,  when  the  nurse  found  the  sponge  outside;  it  had  care- 
lessly been  misplaced  in  a  jar  and  overlooked.  The  patient  fortunately 
recovered. 


136  GENERAL  PRINCIPLES 

These  two  cases  illustrate  the  degree  to  which  a  surgeon,  with  all 
the  responsibility,  may  be  powerless  to  protect  his  patient  against  the 
inefficiency  or  carelessness  of  an  assistant  whose  shortcomings,  per- 
chance, he  may  be  unable  to  discover  until  it  is  too  late. 

The  precautions  which  may  be  taken  in  order,  so  far  as  possible, 
to  guard  against  accidentally  leaving  a  sponge  in  the  abdominal  cavity 
are  as  follows: 

1.  All  sponges  should  be  so  large  as  not  easily  to  be  overlooked  by 
the  operator.  If  sea-sponges  are  used,  let  them  all  be  the  largest  flat 
sponges,  and  of  as  nearly  uniform  size  as  possible.  Gauze  sponges  are, 
however,  preferable.  They  should  be  made  of  good  absorbent  gauze 
in  four  thicknesses,  and  should  be  of  uniform  size,  at  least  six  inches 
wide  by  twelve  to  sixteen  inches  long.  All  sponging  can  be  done 
with  large  as  well  as  with  small  sponges.  Let  the  smaller  ones,  then, 
be  discarded.    They  serve  no  necessary  purpose. 

2.  All  sponges  designed  for  abdominal  section  should  be  kept  in 
packages  of  eight  each.  This  number  will  suffice  for  the  ordinary 
operation.  If  more  are  needed,  additional  packages  may  be  opened. 
As  soon  as  a  package  is  opened,  the  sponges  should  accurately  be 
recounted  and  recorded.  Invariably  this  precaution  will  fix  the  number 
for  any  operation  at  eight  or  a  multiple  of  eight. 

3.  Toward  the  close  of  the  operation  the  sponges  again  should  be 
counted.  Experience  has  shown  that  under  the  demoralizing  influence 
of  hurry  and  excitement  which  often  attend  the  close  of  a  desperate 
operation,  the  nurse  in  charge  of  the  sponges  is  liable  to  blunder  in  the 
count.  It  is  well,  therefore,  that  the  count  be  repeated  two  or  three 
times,  and,  if  possible,  by  different  individuals. 

Another  practical  means  of  avoiding  the  loss  of  sponges  that  may 
have  been  packed  into  the  abdomen  is  to  have  them  fastened  in  groups 
of  two  by  narrow  strips  of  tape.  Figure  68,  B,  the  strips  being  about 
twelve  inches  long.  One  might  readily  overlook  one  sponge  in  the 
cavity,  but  he  could  hardly  overlook  two.  Moreover,  sponges  fastened 
together  in  this  way  are  counted  easily  when  removed.  The  plan  of 
attaching  a  tape  to  each  sponge  and  letting  the  end  remain  outside  is 
objectionable,  for  many  protruding  strips  of  tape  would  be  in  the  way 
of  the  operator,  and,  what  is  worse,  one  or  more  strips,  even  though 
held  by  forceps,  might  accidentally  slip  in  and  be  lost.  The  long 
sponge  roll  of  INIayo,  Figure  68,  C,  is  most  serviceable  for  packing 
intestine  out  of  the  way  of  the  operator. 

The  operator,  whose  every  energy  is  employed  in  the  effort  to  shorten 
the  time  of  operation,  cannot  stop  for  sponge-counting;  yet  only  a 
surgeon  can  appreciate  the  satisfaction  which  lies  in  the  absolute 
knowledge  that  every  sponge  is  out.  The  writer,  therefore,  now  uses 
a  simple  device  by  which  the  number  of  sponges  may  at  a  glance  be 
apparent  to  anyone.  It  is  this:  At  the  time  of  closing  the  wound 
the  sponges  are  arranged  in  uniform  rows  on  the  floor.  The  subject 
is  so  urgent  that,  even  at  the  risk  of  a  seeming  triviality,  the  accom- 
panying illustration  is  introduced. 


.]f.\ji)h'  ()i'h:h'.\ri()\'S 


137 


'riuT(>  arc  mniiit'cst  ;ul\aiit;i,ucs  in  not  liaxiii-  tlic  spon^ics  waslu-d 
durinu'  (hi-  oprratioii.  A  sufHcicnt  numlu'r  should  hv  i)r()vi(k'd,  so 
tliat  thry  may  alwa.xs  \n-  used  drx',  and  discarded  as  soon  as  they  are 
soiled.  In  this  \va\  the  oi)erator  may  dispense  with  one  assistant,  the 
sponu'e-wasluT,  and  so  limit  the  danii'er  of  inl'eetion. 


A.  gauze  sponsje  on  long  forceps  for  deep  sponging:  in  the  pelvic  or  abdominal  cavity:  B.  gauze  sponge 
fastened  together  with  tape  as  a  precaution  against  leaving  it  in  the  peritoneal  cavity;  C.  long  sponge 
roll  for  packing  intestines  out  of  operator's  way. 

How  to  Avoid  the  Leaving  of  Instruments  in  the  Abdomen. — All  instru- 
ments should  be  counted  and  the  number  recorded  before  and  after 
operation;  at  least  one  assistant  should  be  responsible  for  these  count- 
ino;s.  Special  attention  should  be  paid  to  the  forceps,  since  these  are 
the  instruments  most  frequently  lost.    The  operator  is  strongly  urged 


138 


GENERAL   PRINCIPLES 


to  avoid  the  use  of  the  ordinary  short  six-inch  haemostatic  forceps  and 
substitute  in  their  place  long,  strong  eight-inch  forceps  of  heavy  blades. 
These  instruments  are  always  serviceable,  usuall}^  more  serviceable 
than  the  smaller  ones,  and  are  much  less  likely  to  be  misplaced  or  lost. 
They  are  particularly  useful  in  hsemostasis  of  the  wound  during  and 
after  the  abdominal  incision,  since  they  project  out  on  either  side  of 
the  wound  and  by  their  own  weight  hold  themselves  and  the  margins 
of  the  wound  in  place.  When  used  in  the  abdominal  cavity  the  handles 
project  far  outside  of  the  wound  so  that  they  do  not  readily  slip  inside 
and  escape  notice. 

Figure  69 


Sponges  arranged  in  rows  to  facilitate  counting  at  the  end  of  an  operation. 

Dressings  and  Bandages. — The  usual  combination  aseptic  dressing 
of  gauze  and  wood-wool  or  cotton,  secured  by  strips  of  adhesive  plaster 
and  a  firm  abdominal  bandage,  will  suffice.  The  nurse  should  be  cau- 
tioned to  use  care  lest  the  dressing  and  bandage  slip  up  and  expose 
the  lower  end  of  the  wound.  If  a  vulvar  dressing  also  is  used,  it  should 
be  kept  separate  from  the  abdominal  dressing,  for  otherwise  fluids 
may  pass  by  capillary  attraction  from  one  to  the  other ;  this  may  explain 
the  fact  that  stitch  abscesses  often  begin  at  the  lower  end  of  the  wound. 
It  is  well  to  use  two  abdominal  bandages,  one  to  reach  from  the  hips 
to  the  umbilicus,  or,  if  necessary,  higher,  and  the  other  to  lap  over  the 
lower  part  of  this  and  reach  to  the  middle  of  the  thighs.  The  lower 
bandage  keeps  the  dressing  from  slipping  upward.  It  may  be  loosened 
for  movement  of  bowels  or  urination. 

Dusting  Powders  for  the  Wound. — The  author  has  used  dusting  powders 
extensively  and  with  good  results,  but  recent  experience  has  convinced 


MAJOR  OI'ERATIONS 


130 


liim   that  in  careful  aseptic  siirj^^cry  all   dnstiiij;-  powders  may   he  dis- 
|)ensc(l  with  to  a(l\aiita<i;e. 


B 


f^'^ 


A.  two  layers  of  gauze  with  cotton  between  lying  on  the  closed  wound;  B.  gauze  and  cotton  dressing 
being  secured  in  place  by  means  of  a  wad  of  cotton  held  in  the  grasp  of  a  forceps  and  saturated  with 
collodion;  C,  gauze  and  cotton  dressing  further  held  in  place  by  means  of  perforated  adhesive  plaster. 
Observe  this  plaster  in  three  pieces,  the  two  lower  pieces  being  placed  parallel  to  Poupart's  ligament 
so  that  on  retraction  of  the  thighs  the  plaster  will  not  be  Ufted  off. 


140 


GENERAL  PRINCIPLES 


111  ordinary  cases  in  which  there  is  Httle  probability  that  the  wound 
will  have  to  be  dressed  or  otherwise  disturbed,  it  is  better  to  apply 
the  dressings  and  secure  them  by  perforated  adhesi\'e  plaster,  as  shown 
in  Figure  70.  The  wound  is  covered  first  by  a  single  layer  of  gauze. 
This  gauze  is  made  fast  by  means  of  collodion.  In  order  not  to  con- 
fine any  possible  secretion  which  may  escape  from  the  wound,  the 
collodion  should  surround,  but  should  not  cover,  the  line  of  union. 
On  this  layer  of  gauze  is  placed  a  layer  of  absorbent  cotton,  and  over 
the  cotton  a  second  layer  of  gauze,  Figure  70,  A  and  B,  which  also  is 
made  fast  by  collodion.  A  few  additional  layers  of  gauze  are  now 
loosely  placed  over  that  part  of  the  dressings  already  described,  and 
the  whole  is  held  in  place  by  perforated  adhesive  plaster,  as  shown  in 
Figure  70,  C.  The  advantages  of  holding  the  dressings  in  place  by 
means  of  adhesive  plaster  instead  of  the  usual  abdominal  binder  are 


Figure  71 


This  Figure  shows  perforated  plaster  over  the  dressings  of  an  abdominal  wound.  This  is  the  usual 
method  of  application,  but  is  faulty,  because  when  the  thighs  are  retracted  the  plaster  is  apt  to  be 
lifted  from  the  wound.     The  correct  method  is  shown  in  Figure  70. 

as  follows:  (1)  the  wound  is  protected  absolutely  against  exposure  by 
the  carelessness  of  nurses,  who  are  prone  to  permit  the  abdominal  binder 
to  be  displaced  upward,  and  thereby  to  leave  the  wound  exposed; 
(2)  the  dressings  of  the  gauze  and  cotton,  secured  by  collodion  and 
covered  by  perforated  plast-er,  give  the  patient  much  less  discomfort 
than  the  ordinary  cumbersome  dressings  of  large  quantities  of  gauze, 
cotton,  and  other  absorbent  materials,  which  are  held  in  place  by  the 
conventional  abdominal  binder. 


2.  VAGINAL   SECTION 

The  vaginal  route  for  opening  into  the  peritoneal  cavity  is  often 
Dreferable.    The  incision  mav  be  made  between  the  uterus  and  rectum 


MAJOR  OI'l'JhWTIONS  141 

or  ht'twtTii  tlu'  utiTiis  ;iii(l  Ijladdcr.  'I'lir  tccliiii(|uc  of  the  procedure 
varies  within  wide  limits,  and  will  l)e  described  under  special  opera- 
tions. See  \'a,i,'inal  Section  in  the  cliapter  on  the  Treatment  of  Pelvic 
InHanimation. 

'A.  SACRAL   RESECTION 

Hysterectomy  and  other  intrapehic  operations  have  been  performed 
throujjh  an  oj^enini,'  made  by  resection  of  the  sacrum  after  the  method 
of  Kraske.    The  precise  ^■alue  of  the  method  has  not  been  established. 


CHAPTER    VII 
DRAINAGE  IN  IMAJOR  OPERATIONS 

INFECTIOUS    AND    NON-INFECTIOUS    CASES 

Two  classes  of  drainage  cases  present  themselves;  ^r^^,  cases  which, 
up  to  the  time  of  operation,  are  free  from  infection;  second,  cases  in 
which  infection  has  occurred  previous  to  the  operation.  To  the  first 
class  belong  solid  and  cystic  tumors  and  tubal  pregnancies  which  have 
not  become  infected;  to  the  second  class  belongs  pelvic  inflammation 
in  its  various  forms  and  stages,  such  as  inflammation  of  the  Fallopian 
tube  and  ovary,  including  pelvic  abscess,  pyosalpinx,  and  infected 
tumors. 

In  the  non-infectious  cases  drainage  has  been  resorted  to  for  the  re- 
moval of  blood,  serum,  or  other  non-infectious  fluids  such  as  otherwise 
might  accumulate  in  the  peritoneum,  and,  if  left  there,  become  infectious. 
Experiment  and  experience,  however,  have  shown  that  the  non-infected 
blood  and  serum  which  may  accumulate  in  the  peritoneum  after  a 
clean,  adequate  operation  have  little  or  no  power  for  harm.  Serum 
and  hquid  blood  are  absorbed  rapidly.  Coagulated  blood  may  be  ab- 
sorbed, or  it  may  become  encapsulated  and  gradually  removed  by  the 
action  of  leucocytes;  or  it  may  become  organized  and  remain  harmless 
for  an  indefinite  period.  Both  blood  and  serum  are  excellent  culture- 
media  for  microbes;  hence  the  necessity  to  keep  them  non-infectious 
by  aseptic  surgery.  The  peritoneum  has  great  power  to  resist  infection, 
and  is  known  to  take  up  and  dispose  of  large  quantities  of  infectious 
material,  even  without  drainage.  Recent  studies  and  experience  prove 
that  the  drain  is  often  more  potent  as  a  medium  for  the  introduction 
of  sepsis  than  for  the  removal  of  it.  Drainage,  on  account  of  infection, 
therefore,  after  a  clean  operation  in  a  case  not  hitherto  infected,  is 
contra-indicated . 

Bacteriological  examinations  of  reproductive  organs  removed  for 
chronic  inflammatory  disease  frequently  show  that  the  pus  is  sterile, 
or,  if  organisms  are  present,  they  may  be  inactive  at  the  time  of  the 
operation.  Formerly  the  escape  of  the  smallest  quantity  of  pus  into 
the  peritoneum  during  an  operation  was  considered  an  imperative 
indication  for  drainage.  Now,  the  escape  of  even  large  quantities  if 
free  from  virulent  or  active  microbes  does  not  call  for  drainage. 

Comparison  of  Results. — Large  numbers  of  drained  pus-cases  and 
equal  numbers  of  like  cases  not  drained  uniformly  show  a  strong 
preponderance  of  recoveries  in  the  non-drainage  series.  This  prepon- 
(142) 


DRAINAGE  IN  MAJOR  OPERATIONS  143 

derance  is  proof  that  the  draiimji^e  was  useless,  and  that  the  hirj^er 
inortaHt\'  in  tlic  (h^iincd  oases  is  attributable  to  infection  intro(hiced 
tlirouiili  the  drain. 

Evil  Results  of  Drainage. — In  addition  to  the  greatly  increased 
dan,i;er  already  mentioned  from  the  direct  introduction  of  infection 
throui^h  the  medium  of  the  drain,  the  following  evil  results  of  drain- 
age may  be  mentioned  as  not  infrequent: 

1.  Obstruction  of  the  bowel. 

2.  Fecal  fistula. 

3.  Vesical  complications. 

4.  Hernia. 

5.  Intoxication  by  iodoform  gauze  or  other  medicated  gauze. 

1.  Obstruction  may  occur  from  adhesions  set  up  by  the  irritating 
presence  of  the  drain.  An  adherent  intestine  sharply  kinked  may 
become  suddenly  impermeable,  or  gradually  contracting  bands  may 
shut  oti'  its  lumen  slowly.  Most  frequently  the  obstruction  is  partial, 
and  gives  rise  to  constipation  and  griping  pains,  for  days  or  weeks  after 
the  operation.  In  such  cases,  when  fatal,  the  autopsy  usually  has 
shown  the  intestines  matted  around  the  drainage  cavity  in  an  unrecog- 
nizable mass. 

2.  Fecal  Fistula  is  the  occasional  result  of  necrosis  from  direct  pressure 
of  the  drain  or  from  the  irritating  presence  of  a  gauze  drain  and  con- 
sequent infection  so  destructive  as  to  produce  necrosis  and  consequent 
fistula.  If  the  bowel  has  been  opened  during  an  operation,  and  has  been 
well  repaired,  drainage  is  unfavorable  to  union  and  is  contraindicated. 
If,  however,  the  intestinal  opening  has  been  made  deep  in  the  pelvis, 
or  is  otherwise  so  inaccessible  as  to  prevent  thorough  suturing;  if,  in 
a  word,  union  is  improbable,  drainage  is  indicated  as  a  means  of  exit 
for  fecal  matter. 

The  greatest  care  in  covering  all  raw  surfaces  with  peritoneum  and 
stitching  it  down  with  fine  continuous  catgut  sutures  is  one  of  the 
most  imperative  measures  for  the  reduction  of  mortality  in  abdomi- 
nal surgery;  even  the  bad  condition  of  a  patient  and  the  necessity 
for  rapid  operating  will  seldom  be  an  excuse  for  neglect  of  this  pre- 
caution. 

3.  Vesical  Complications. — The  territory  to  be  drained  is  usually  in 
close  relation  with  the  bladder.  Infection  around  the  drain,  therefore, 
may  give  rise  to  adhesions  between  the  bladder  and  adjacent  organs, 
or  may  invade  the  bladder;  in  either  case  vesical  disturbance  more  or 
less  severe  may  arise. 

4.  Hernia  in  drained  cases  is  much  more  common  than  usually  is 
supposed.  This  is  because  the  drain  separates  the  fascial  sheaths  of 
the  recti  muscles  and  other  surfaces  which  otherwise  would  unite 
immediately;  the  small  breach  thus  made  in  the  wall  increases,  and 
more  or  less  hernia  is  the  result.  Hernia  less  often  results  from  vaginal 
than  from  abdominal  drainage. 

To  Prevent  Infection,  and  thereby  to  avoid  the  necessity  for  drainage, 
is  an  essential  purpose  of  every  abdominal  section.    The  subject  may 


144  GENERAL   PRINCIPLE!^ 

be  summed  up  in  the  proposition  that  the  operation  should  be  performed 
in  such  a  way  as  not  to  require  drainage.  This  involves  the  following 
precautions : 

1.  Insure  thorough  asepsis  of  hands,  instruments,  and  other  appli- 
ances.   See  Chapter  II.,  on  Antiseptics  and  Asepsis. 

2.  Avoid  all  unnecessary  injury  of  the  tissues.  All  traumatisms 
favor  sepsis.  Do  the  ojjeration  adequately,  but  with  the  least  possible 
amount  of  operating. 

3.  Wherever  the  peritoneum  is  denuded  or  otherwise  injured,  let  the 
injured  part,  if  possible,  be  covered  by  adjacent  peritoneum.  This 
may  require  numerous  sutures  and  careful  plastic  work. 

4.  Control  hemorrhage,  if  practicable,  even  to  small  oozing  points. 
This,  for  want  of  time  or  for  other  reasons,  may  be  impracticable.  It 
may  then  be  safer  to  leave  small  accumulations  to  be  taken  up  by  the 
peritoneum  rather  than  by  a  drain. 

5.  As  a  most  important  precaution,  let  the  boweh  be  evacuated 
thoroughly  before  beginning  the  operation.  Any  considerable  quantity 
of  gas  in  the  bowel  since  it  impedes  the  operator,  prolongs  the  opera- 
tion, and  retards  convalescence,  is  a  source  of  danger.  As  much  as 
two  ounces  of  castor  oil  may  advantageously  be  given  the  second  day 
or  the  day  before  operation. 

6.  Flushing  the  peritoneal  cavity  by  means  of  normal  salt  solution  has 
in  times  past  with  many  surgeons  been  a  favorite  procedure  against 
infection.  This  practice  now  has  become  nearly  obsolete  except  in 
cases  of  very  extensi^'e  soiling  of  the  abdominal  cavity  with  septic 
material  from  ruptured  ovarian  cyst  or  ruptured  tubal  pregnancy,  or 
general  diffusion  of  pus  throughout  the  peritoneum,  this  is  because  the 
peritoneum  has  extraordinary  capacity  to  take  up  and  dispose  of  septic 
material.  Great  experience  and  judgment  even  may  not  enable  the 
surgeon  to  choose  wisely  on  questions  of  flushing  and  drainage.  If 
the  cavity  is  to  be  washed  out  it  is  usual  to  pour  salt  solution  through 
the  wound  from  a  pitcher  or  flask.  This  method  is  inadequate  because 
the  cavity  may  be  so  filled  with  viscera  that  the  solution  thus  introduced 
cannot  reach  the  deeper  portions  of  the  abdomen  or  pelvis.  In  order 
to  make  the  flushing  effective  the  solution  may  be  introduced  through 
a  cannula  attached  to  a  rubber  tube,  the  tube  leading  from  a  reservoir 
above.  The  end  of  this  cannula  can  be  passed  through  the  wound  and 
made  to  transmit  the  solution  thoroughly  to  all  parts  of  the  peritoneal 
cavity.  A  very  practical  substitute  for  the  cannula  is  shown  in  Figure 
72.  The  salt  solution  is  held  in  a  funnel-like  metallic  reservoir,  to  which 
is  attached  a  rubber  tube  at  least  three-fourths  of  an  inch  in  diameter. 
At  the  end  of  this  tube  is  fastened  a  long  straight  pressure-forceps, 
as  shown  in  Figure  72.  By  means  of  this  forceps  the  end  of  the  rubber 
tube  may  be  carried  into  any  part  of  the  peritoneal  cavity,  and  the 
solution  rapidly  and  thoroughly  introduced  in  very  large  quantities. 
During  the  process  of  flushing  additional  quantities  of  solution  may  be 
poured  from  pitchers  into  the  metallic  reservoir.  By  this  means  many 
gallons  of  solution  may  be  brought  rapidly  in  contact  with  every  part 


DRAIN  ACE   l.\    MAJOR  OI'ERAT/OXS 


14o 


of  the  peritonoal  cavity.  In  iisiii<r  this  apparatus,  it  is  essential  that 
there  l)e  a  free  outlet  thruuji;h  the  wound,  for  otlierwise  the  jjressure 
exerted  upon  tlie  (Haphragni  l)y  the  column  of  water  nii<,dit  he  dan<,a'rous. 
I'siMu  salt  water  at  a  temperature  l(t,3°  has  great  value  in  stock  during 
an  o])eration. 


FlGLKE    72 


Apparatus  for  flushing  out  abdominal  cavity,  consisting  of  a  metal,  funnel-like  resen"oir  with  two 
handles  to  be  held  above  the  level  of  the  patient.  A  rubber  tube  three-fourths  of  an  inch  in  diameter 
leads  from  the  reser\'oir.  At  the  end  of  the  tube  may  be  attached  a  cannula,  or  as  shown  in  the 
Figure  a  forceps,  for  the  purpose  of  carrj-ing  the  solution  to  the  deeper  parts  of  the  peritoneal  ca\-ity. 


CONTRAINDICATIONS    FOR    PERITONEAL    DRAINAGE 


Dramage  is  contraindicated  under  the  following  conditions : 
1.  Aseptic  operations  in  which  there  is  no  pus  or  other  source  of 
infection. 
10 


146  GENERAL   PRINCIPLES 

2.  Operations  in  which  there  is  pus,  but  in  which  the  sac  containing 
it  is  removed  intact  so  that  no  pus  has  escaped. 

3.  Operations  in  which  pus  has  escaped,  but  where  immediate  micro- 
scopical examination  of  a  smear  shows  it  to  be  sterile. 

INDICATIONS    FOR   PERITONEAL    DRAINAGE 

Drainage  is  indicated  in  the  following  class  of  cases: 

1.  General  septic  peritonitis. 

2.  The  presence  of  a  localized  pus-producing  surface  which  ma\ 
continue  to  secrete  a  greater  amount  of  septic  matter  than  the  perito- 
neum can  take  up,  and  which  therefore  may  be  a  dangerous  source  of 
infection.  Under  these  conditions  drainage  is  indicated  at  the  time 
of  operation.  The  source  of  infection  may  be  a  damaged  intestine;  an 
abscess;  an  adherent  necrotic  irremovable  cyst;  an  infected  hsemato- 
cele,  or  an  abundance  of  necrotic  tissue  which  cannot  safely  be  removed. 
The  presence  of  free  pus  in  the  abdominal  cavity  at  the  time  of  an 
operation  raises  a  difficult  cjuestion.  If  the  pus  contains  ^•ery  virulent 
bacteria,  for  example,  streptococci,  many  surgeons  would  hesitate  to 
close  the  wound  without  drainage.  On  the  contrary,  others  who  depend 
upon  the  power  of  the  peritoneum  to  take  up  and  neutralize  septic 
matter,  are  inclined  to  follow  a  routine  practice  of  non-drainage,  and 
claim,  not  without  evidence,  that  the  average  results  are  superior 
under  the  non-drainage  method.  If,  during  the  operation,  on  micro- 
scopical examination  of  a  smear,  streptococcus  infection  were  found,  I 
would  be  disposed  to  open  through  the  cul-de-sac  of  Douglas  and  drain 
into  the  vagina.  If  after  an  operation  infectious  fluid  becomes  walled 
off  by  plastic  effusion,  thereby  forming  an  abscess,  no  time  should  be 
lost  in  opening  and  draining  it. 

3.  Hemorrhage,  for  the  control  of  which  the  ligature,  forcipressure, 
and  hot  sponge  packing  are  inadequate. 

DIFFERENT    FORMS    OF   DRAINAGE 

Tubular  Drainage  is  usually  through  soft  rubber  or  small  glass  tubes. 
For  drainage  through  the  vagina  rubber  is  preferable  to  glass.  The 
tube  is  especially  useful  as  a  medium  for  drainage  and  for  washing 
out  septic  cavities,  such  as  abscesses  which  have  been  walled  off  by 
plastic  lymph  from  the  general  peritoneum.  The  presence,  however, 
of  a  tube  in  the  peritoneal  cavity  usually  causes  in  a  few  hours  the 
surrounding  organs  to  be  fused  together.  The  space  which  the  tube 
occupied  is  isolated  then  from  the  remainder  of  the  peritoneum,  and 
is  the  only  space  which  it  possibly  can  drain.  For  this  reason  tubular 
drainage  in  the  abdomen  for  the  most  part  has  been  discarded. 

Capillary  Drainage. — The  continuous  strip  of  gauze  has  been  used 
extensively  for  capillary  peritoneal  drainage  through  botli  the  vaginal 
and  the  abdominal  wound. 


Dh'MXACr:   l.\    MAJOli  OI'ERATIOSS 


\A\ 


There  tire  two  prliiripdl  iiidlcdlioiis  far  the  use  af  f/ditze  parking  in 
alxloriiiiial  and  pcKic  operations:  (I)  licinorrlia^^c  wliicli  cannot  be 
c'ontrolli'd  practically  in  any  other  way  withont  nndnly  prolonginj;  the 
opcratit)n;  the  packing-  then  used  is  inunediately  a  compress,  but  if 
left   longer  than    is  necessary  for  lueniostatic  purposes  it  becomes  a 


Reid's  rubber  drain,  .4,  B,  C,  D.  This  drain  has  two  wings,  C,  which  make  it  self-retaining  wlien 
placed  in  a  pus-ca'V'ity.  The  wings  may  be  held  together  by  forceps,  D,  to  facilitate  introduction; 
.1,  a.  and  C  show  the  steps  in  the  formation  of  the  drain;  E,  F,  crdinarj-  double  rubber  drains;  G,  a 
rubber  drain  surrounding  a  roll  of  gauze  for  capillary  drainage:  H,  ordiuarj-  glass  drainage-tube  for 
abdominal  drainage. 


capillary  drain.  (2)  The  desirabil  ty  of  quarantining  a  septic  field  of 
operation  from  the  general  peritoneal  cavity.  The  rapidity  with  which 
adhesions  form  around  the  packing  is  well  known.  In  a  few  hours  a 
septic  area  may  be  shut  off  from  the  general  peritoneum  by  adhesions 
which  form  around  the  gauze  packing,  and  in  this  way  septic  fluid  is 
walled  off,  confined  within  narrow  limits  and  carried  out  by  the  drain. 


148 


GENERAL   PRINCIPLES 


The  use  of  gauze  for  packing  against  hemorrhage  should  not  be 
confounded  with  the  use  of  it  as  a  drain.  The  value  of  gauze  for 
drainage  as  usually  understood— that  is,  for  the  removal  by  capillary 
attraction  of  any  fluid  which  may  form  in  the  peritoneal  cavity— is 


Figure  74 


The  upper  five  rubber  tubes  show  the  steps  in  the  formation  of  Reid's  rubber  drain  for  through- 
and-through  abdominal  drainage.  The  Figure  below  shows  the  drain  in  place  projecting  upward 
thr9ugh  the  lower  end  of  the  abdominal  wound  and  held  there  by  a  safetv-pin.  The  other  end  of  the 
drain  is  projected  downward  from  the  abscess-cavity  through  Douglas'  pouch  and  the  vagina  to  the 
vulva,  tach  end  of  this  dram  is  protected  by  a  gauze  pad.  these  pads  are  held  in  place  bv  an  abdomi- 
nal binder  and  a  T-bandage,  and  should  be  changed  sufficiently  often  to  keep  them  dry. ' 

overestimated  as  above  stated.  The  peritoneum  often  has  demonstrated 
its  ability  to  take  care  of  large  quantities  of  secretion.  If,  as  many 
assert,  it  be  true  that  the  presence  of  a  drain  excites  the  secretion  of 
quantities  of  fluid  which  would  not  otherwise  be  secreted,  it  follows 


DHMSAdE  IS  MAJOh'  (>ri<:h'A'n(>.\s 


14!  I 


that  the  drain  is  often  not  so  necessary  as  the  lar^c  (|uantities  of  finid 
which  it  carries  olf  would  seem  to  indicate.  Clearly  it  would  he  absurd 
to  use  a  drain  for  the  purj)()se  of  carryinff  oil'  secretions  which  it  had 
itself  excitetl.  Moreover,  the  gauze  packing  often  acts  as  an  obstruc- 
tion to  the  removal  of  fluids,  and  may  therefore  defeat  the  purpose  of 
(irainage. 

Drainage  through  the  Abdominal  Wound,  if  emi)loye(l,  may  be 
either  by  the  tubular  or  by  the  capillary  method.  The  route  from  the 
pelvis  to  the  abdominal  wound  is  long  and  in  close  relations  with  the 


FuiLKB    7.3 


Vaginal  gauze  drain  extending  from  Douglas'  pouch  to  the  vulva  for  capillary  drainage.  A  large 
gauze  pad  should  be  kept  over  the  vulva,  and  changed  often  enough  to  keep  it  dry.  This  pad  is  secured 
by  a  T-bandage. 


bladder,  intestines,  and  omentum,  which  organs  should  have  no  neces- 
sary relation  with  the  field  of  operation,  but  which,  from  contact  with 
the  drain,  are  unfortunately  liable  to  infection,  adhesions,  perforation, 
and  hernia.  ^Moreover,  the  long  sinus  left  after  removal  of  the  drain 
is  often  slow  to  heal,  and  its  outer  end  is  prone  to  contract  rapidly 
and  leave  in  the  pelvis  a  troublesome,  undrained,  or  imperfectly  drained 
pocket.  For  these  reasons  the  abdominal  route  for  drainage  presents 
disadvantages  and  usually  should  be  limited  to  special  cases  in  which 
there  are  practical  difficulties  in  prolonging  the  operation  by  opening 
into  the  vagina  or  in  which  the  condition  demands  more  general  drain- 
age of  the  peritoneum  than  is  possible  by  the  vaginal  route  alone. 


150 


GENERAL   PRINCIPLES 


Abdominal  drainage  if  required  at  all  will  be  limited  for  the  most  part 
to  cases  which  require  that  the  drainage  be  most  thorough.  It  is  best 
secured  by  means  of  rubber  tubes,  an  inch  in  diameter,  split  on  one 
side  the  whole  length,  and  containing  a  roll  of  gauze — cigaret  drain. 
Three  of  these  drains  should  be  used :  one  in  each  flank  and  one  in  the 
cul-de-sac  of  Douglas.  The  patient  then  should  be  placed  in  the  ex- 
aggerated Fowler  position,  that  is,  the  shoulder  should  be  at  least  twenty 


Figure  76 


Capillary  drainage  through  abdominal  wound;  the  gauze  pad  held  by  the  hand  is  to  be  placed  over 
t*  e  wound"  in  contact  with  the  protruding  portion  of  the  drain.  This  pad  should  be  secured  by  an 
abdominal  binder,  and  changed  often  enough  to  keep  it  dry.  As  already  stated  this  form  of  drainage 
seldom  is  permissible  except  for  emergency  control  of  hemorrhage. 


inches  above  the  hips,  so  that  dependent  and  deep  depressions  in  the 
peritoneal  cavity  may  be  drained  by  gravity.  Such  drainage  is  de- 
manded only  in  extreme  acute  cases  of  present  or  threatened  peritonitis 
and  calls  for  great  experience  and  judgment. 

Vaginal  Drainage. — The  route  from  the  pelvic  cavity  to  the  vagina 
is  short  and  direct;  hence  the  vaginal  drain  is  generally  preferable.  If 
in  the  operation  an  opening  between  the  pelvic  cavity  and  the  vagina 


l>h'M.\A(;i-J  l.\    MAJOIx'  OI'Kh'ATlONS  151 

luis  not  hiH'ii  iiKidc  and  (li'aiiiau'c  is  necessary,  it  is  often  Ix'tter  to  make 
an  opening;'  for  that  purpose.  'Hie  ^reat  a(lvaiita<i;es  of  the  \a^iiial 
route  are:  (1)  miuiinuni  risk  of  hernia;  (2)  natural  and  dependent  drain- 
age; {'A)  more  satisfaetory  convalescence.  Tiie  safety  of  this  route 
must  (K'i)end  largely  upon  pre\'ious  thoroujih  (Usinfeetion  of  the  \agina. 

If  the  xati'iual  gauze  drain  is  to  he  j)assed  after  an  abdominal  opera- 
tion throuti'Ii  an  opening  made  from  the  peritoneal  cavity  into  the 
vagina  for  that  i)urpose,  one  may  first  pack  the  strip  of  gauze  into  a 
previously  disinfected  vagina,  crowding  it  well  into  the  posterior 
vaginal  fornix,  where  it  can  easily  be  felt  with  the  finger  in  the  pouch 
of  Douglas.  The  operator  then,  using  this  i)acking  as  a  guide,  may  cut 
down  directly  upon  it.  This  incision  thus  made  may  be  enlarged  to 
the  required  degree,  after  which  the  upper  end  of  the  gauze  may  be 
drawn  from  the  vagina  into  the  peritoneum,  and  the  gauze  already 
being  in  place,  that  part  of  the  operation  is  comj)lete.  Another  very 
serviceable  method  is  to  pack  the  gauze  strip  firmly  into  the  pelvic 
cavit}^,  a  free  end  of  it  being  in  the  cul-de-sac  of  Douglas,  and  close 
the  abdominal  wound;  then  through  a  \-aginal  retractor  cut  through 
the  posterior  fornix  of  the  vagina  into  the  cul-de-sac,  and  draw  a 
proper  amount  of  the  gauze  into  the  vagina.  See  description  of  aseptic 
vaginal  packing  in  a  paragraph  under  Preparation  of  the  Vagina,  near 
the  end  of  Chapter  II. 

The  manner  of  introducing  a  gauze  drain,  whether  abdominal  or 
vaginal,  is  as  follows:  The  end  of  a  continuous  strip  of  double  gauze, 
with  the  edges  turned  in  and  stitched  together  to  prevent  fraying,  is 
doubled  backward  and  forward  upon  itself,  like  the  folds  of  a  fan, 
from  the  part  to  be  drained  to  the  surface.  Over  this  an  external 
dressing  is  placed  and  changed  as  often  as  it  becomes  saturated. 
Figures  74,  75   and  76  show  vaginal  and  abdominal  drains  in  place. 

The  time  for  removal  of  gauze  varies  with  the  purpose  for  which 
it  was  used ;  if  to  control  hemorrhage,  it  should  be  removed  in  twenty- 
four  hours;  if  for  drainage,  it  may  be  left  five  days,  unless,  as  occa- 
sionally happens,  it  acts  as  an  impediment  to  drainage.  Some  surgeons 
co7isider  the  gauze  objectionable  as  soon  as  it  becomes  saturated.  In  this 
connection  we  may  again  emphasize  the  importance  of  keeping  the  dress- 
ing over  the  drain  absorbent  and  dry.  The  writer  repeatedly  has  observed 
patients  to  show  signs  of  septic  absorption  on  the  second  or  third  day 
after  an  abdominal  operation,  when  removal  of  the  gauze  was  fol- 
lowed by  a  gush  of  pent-up  fluid  and  prompt  relief  of  all  urgent  symp- 
toms. It  is  not  usually  necessary,  after  removal  of  the  original  drain, 
to  introduce  fresh  gauze.  If  at  any  time  the  opening  tends  to  con- 
tract too  rapidly,  or  drainage  becomes  imperfect,  the  gauze  may  be 
renewed  or  a  tube  may  be  inserted. 

The  classical  dictum  has  been,  "Wheii  in  doubt,  drain.''  If,  however, 
the  irritating  influence  of  the  drain  is  to  cause  the  secretion  of  fluid  which 
otherwise  would  not  be  secreted;  if  the  peritoneum,  left  to  itself,  is  capable 
of  taking  up  and  disposing  of  large  quantities  of  fluid,  even,  to  some  extent, 
of  septic  fluid;  if  the  drain  is  more  prone  to  introduce  than  to  carry  ant 
sepsis — then  the  dictum  may  hare  to  be  reversed,  when  in  doubt,  don't  drain. 


CHAPTER  VIII 
AFTER-TREATMENT  IN  MAJOR  OPERATIONS 

AFTER-TREATMENT   IN   SIMPLE   CASES 

Watchful  expectancy  is  the  rule  of  after-treatment  in  peritoneal 
surgery.  Indeed,  if  properly  performed,  an  abdominal  section  usually 
is  followed  by  normal  convalescence,  and  therefore  requires  little  or  no 
active  treatment. 

Importance  of  Rest. — Bodily  and  mental  rest  is  the  first  considera- 
tion. The  exclusion  of  relatives  and  friends  from  the  bedside  is  usually 
imperative,  and  will  not  be  difficult  if  properly  managed.  They  have, 
perhaps,  travelled  long  distances,  and  seriously  believe  that  the  com- 
fort and  consolation  which  they  alone  can  give  are  highly  essential 
to  the  patient's  recovery.  They  must  be  told  in  kindly  but  positive 
words  that  the  results  of  experience  in  thousands  of  cases  demonstrate 
the  necessity  of  absolute  quiet;  that  the  presence  of  the  husband,  the 
mother,  or  other  near  relatives  excites  emotion;  that  emotion  consumes 
energy,  of  which  the  patient  has  none  to  spare.  Such  a  statement  is 
usually  sufficient;  if  not,  the  surgeon  must  enforce  whatever  regula- 
tions the  welfare  of  the  patient  may  demand.  If  she  becomes  restless 
and  anxious  because  the  relatives  are  kept  out,  it  may  be  well  to  admit 
them.  ]\Iost  patients,  however,  during  the  first  two  or  three  days  do 
not  ask  for  them,  and  many  prefer  not  to  see  them.  Frequently  sponge- 
bathing,  care  to  keep  the  bed-clothing  under  the  patient  smooth, 
and  such  other  minor  attentions  as  only  a  good  nurse  can  suggest, 
all  contribute  to  the  desired  end,  rest. 

Position. — The  expression  "absolute  rest"  is  misleading  if  it  implies 
the  enforcement  of  the  custom  of  keeping  the  patient  "absolutely 
on  her  back  during  the  first  two  or  three  days."  The  patient  not  only 
becomes  wearied  of  the  fixed  position,  but  is  apt  to  attribute  to  it  the 
inevitable  pain  and  discomfort  of  the  anaesthesia  and  operation.  Unless 
there  is  some  special  objection,  she  should  freely  take  whatever  position 
is  most  comfortable.  She  will  then  wait  more  patiently  for  the  natural 
subsidence  of  the  discomfort,  which  if  all  goes  well  a  little  tinie  will 
bring.  It  is  quite  safe  and  may  be  desirable  at  any  time,  if  the  patient 
wishes,  to  elevate  the  head  and  shoulders  on  a  back-rest,  even  to  the 
extent  of  30  degrees. 

Fowler's  Position,  which  is  secured  by  raising  the  head  of  the  bed 
from  ten  to  twenty  inches,  often  gives  relief  from  nausea  and  nervous 
irritation.     ]\Iany   surgeons  use  this  position  as  a  routine  measure 
immediately  after  operation. 
(152)' 


AFTER-TREAT  ME. XT   1 X    MAJOR  OI'EIiAT  lOXS  lo3 

Rest  for  the  StoiiKich. — A  \-arial)k'  deji^ree  of  irrital)ility  of  the  whole 
digesti\e  tract  is  tlie  coninioii  result  of  anaesthesia,  especially  in  cases 
of  abdominal  section.  The  vomitin*:;  and  nausea  of  this  state  are  in- 
creased rather  than  diminished  by  drugs  and  food.  The  usual  treat- 
ment is  to  withhold  them  until  the  efi'ects  of  the  antesthesia  have  passed 
off.  A  teacui)ful  of  hot  water  slowly  gi\-en,  even  though  [)romptly 
thrown  up,  will  wash  out  the  stomach  and,  perchance,  give  a  little 
relief.  The  knees  may  be  drawn  up  into  the  most  comforta})le  posi- 
tion and  supported  on  a  pillow  or  roll.  The  judgment  and  discretion 
of  a  wise  nurse  will  furnish  a  guide  more  useful  than  the  most  elaborate 
rules.  The  best  nurse  will  move,  when  possible,  along  the  lines  of  least 
resistance,  or,  when  necessary,  will  use  a  gentle  firmness  that  inspires 
confidence.  She  will  carry  her  patient  past  the  critical  period  with  the 
minimum  of  friction  and  discomfort. 

Thirst. — "Oh,  for  a  good  drink!"  is  one  of  the  first  calls.  The 
common  practice  of  withholding  water  as  a  routine  is  to  be  condemned. 
In  the  absence  of  nausea  it  may  be  given  cold  or  hot  in  satisfying 
quantities.  Charged  waters,  ginger  ale,  champagne,  and  other  such 
drinks,  while  not  excluded,  are  not  required,  and  may  do  harm. 

If  in  the  preparatory  treatment  the  patient  has  taken  liberal  quan- 
tities of  water  for  se\'eral  days  and  especially  if  normal  salt-water 
infusion  is  used,  as  set  forth  in  a  following  paragraph  of"  this  chapter, 
there  will  be  little  complaint  of  thirst;  on  the  contrary,  there  will  be 
a  relative  freedom  from  nervousness  and  irritation.  Salt-water  infu- 
sion also  is  clearly  indicated  w^hen  water  is  not  tolerated  by  the 
stomach.  In  some  cases  an  enema  of  salt  solution  every  six  hours  is 
better  tolerated  than  the  infusion. 

Hot-water  Bott'es  and  Bags  placed  about  the  patient  immediately 
after  the  operation  are  useless  except  in  cases  of  shock,  and  should 
be  avoided  as  a  routine.  The  careless  use  of  hot-water  bottles  or  rubber 
bags  before  recovery  from  anoesthesia  has  resulted  occasionally  in  serious 
burns.  In  one  case  the  writer  observed  an  enormous  blister  on  the 
outer  surface  of  each  thigh;  in  another,  on  the  sole  of  the  foot.  Both 
patients  sustained  deep  sloughing  of  the  cutaneous  and  subcutaneous 
structures,  which  finally  required  extensive  skin-grafting.  As  the 
freezing  of  water  in  a  pipe  more  readily  takes  place  when  there  is  no 
circulation  of  water,  so  in  conditions  of  shock,  when  the  circulation  of 
blood  is  feeble,  burns  are  more  liable  to  occur. 

The  Bowels. — If  the  temperature,  pulse,  and  respirations  are  normal, 
or  nearly  so,  and  there  is  no  abdominal  distension  nor  other  unfavorable 
sign,  movement  of  the  bowels  may  be  deferred  until  the  second  day; 
then  they  should  be  moved  by  an  enema  or  a  mild  cathartic.  Some 
surgeons  begin  immediately  after  the  operation  with  half-grain  doses 
of  calomel  given  every  fourth  hour  until  eight  or  ten  doses  have  been 
given  or  the  bowels  act.  If  there  is  no  action,  the  calomel  is  followed 
immediately  by  a  saline  purge  or  an  enema,  or  both. 

If  there  is  nausea  such  that  drugs  are  not  tolerated  by  the  stomach, 
and   enemata  pro\e  inadequate,  physostigmin  sulphate — (hypodermic 


154  GENERAL  PRINCIPLES 

tablets,  grain  one  one-hundredth)  may  be  safely  repeated  twice  as  a 
cathartic  hypodermically  or  extract  of  physostigmin  sterilized  in 
solution  may  be  substituted  hypodermically  in  doses  of  from  one- 
fourth  to  one-tenth  grain. 

Early  catharsis  is  a  good  precaution  against  sepsis  and  peritonitis, 
and  may  be  used  in  all  cases  in  which  these  complications  are  feared. 
In  normal  cases  less  essential.  Early  movement  of  the  bowels,  how- 
ever, is  desirable  in  all  cases.  After  the  initial  movement  they  should 
be  kept  regular  by  cathartics  or  enemas,  or  both. 

The  Bladder. — Great  caution  is  necessary  to  protect  the  patient 
against  the  deplorable  accident  of  distension  and  overflow  of  the  bladder. 
Frequent  urination  should  always  excite  suspicion,  and  should  be 
regarded  as  an  urgent  indication  to  pass  the  catheter. 

Pain  of  variable  degree  is  usually  present  during  the  first  day  or 
two.  Opium  and  its  preparations  lock  up  the  secretions,  induce  nausea, 
arrest  peristalsis,  cause  distension,  and  mask  any  symptoms  which 
otherwise  might  give  warning  of  approaching  danger;  they,  moreover, 
counteract  the  influence  of  cathartics,  and  would  prove  therefore  a 
serious  obstacle  if  it  became  necessary  to  move  the  bowels.  Such  drugs, 
if  given  at  all,  should  be  given  with  great  circumspection.  Codeine 
phosphate  creates  less  nausea,  constipation,  and  other  disturbances 
than  opium  or  morphine;  the  hypodermic  use  of  it  in  half-grain  doses 
is  sometimes  permissible,  during  the  first  twenty-four  hours,  to 
allay  nervous  irritation  and  pain  and  to  insure  needed  rest.  There 
are  conditions  of  great  nervous  irritation  in  which  morphine  in  full 
doses  is  indicated  strongly.  See  Hysterical  Vomiting  in  this  chapter. 
The  operator  is  largely  dependent  upon  the  wdsdom  and  discretion  of 
nurses  and  internes.  The  best  nurses  and  the  best  assistants  manage 
their  ixdients  with  the  least  morphine. 

Food. — Except  in  cases  of  exhaustion,  food  is  to  be  withheld  for 
one  or  two  days.  It  is  usual  to  begin  feeding  after  the  bowels  act  or 
flatus  passes.  Eructations  of  gas  from  the  stomach  are  an  indication 
for  withholding  food.  The  downward  passage  of  flatus  is  a  good 
prognostic  sign.  "Qui  crepitat  vitat,"  said  the  early  Roman  ph3''sicians. 
The  diet  for  the  first  few  days  is  preferably  broth,  beginning  in  small 
doses  and,  according  to  the  tolerance  of  the  stomach,  gradually  in- 
creasing. A  teaspoonful  at  a  time  may  be  given  at  first,  and  repeated 
in  thirty  minutes.  If  this  is  tolerated  the  amount  may  after  a  few  hours 
be  doubled,  and  so  on  till  several  ounces  at  a  time  are  taken.  Finally, 
after  two  or  three  days,  if  all  goes  well,  the  amount  may  be  increased 
largely  until  full  quantities  are  taken. 

Getting  Up. — Ordinarily  the  patient  may  sit  up  about  the  end  of 
the  second  week;  if  the  incision  was  long  and  union  is  not  quite  firm, 
she  should  be  kept  in  bed  longer. 

Care  of  the  Cicatrix. — If  the  sutures  were  non-absorbable  and  have 
been  removed,  the  w^ound  is  to  be  dressed  as  before,  except  with  pro- 
gressively lighter  dressings,  for  a  period  of  two  weeks.  The  new  cicatrix 
should  be  supported  first  by  straps  of  adhesive  plaster,  and  later, 


AFTER-TREATMEST   l\    MAJOR  OI'ERATIOSS  155 

wlu'ii  llir  i);ilifiit  l)cuiii>  to  walk,  \)\  a  |)r()|»crly  adjusted  clastic  l)aiida<,a'. 
A  \aricty  of  suitahlc  haiidajj^cs  may  l)c  found  at  the  iiistniiiieiit  or 
(Iry-tjoods  shops.  'I'he  l)aiula<!:i'  slioiild  l)e  worn  continuously  in  day- 
time for  six  months.  A  liuhter  flannel  hauda^e  may  he  used  at  nij^ht. 
If  the  wound  was  closed  with  chromic  catgut,  as  described  in  Ciiapter 
\  I.,  and  is  not  more  than  two  or  three  inches  long,  and  strong  union 
has  taken  place,  no  abdominal  bandage  is  necessary. 


AFTER-TREATMENT    IN    COMPLICATED    CASES 

Shock  associated  with  abdominal  section  is  the  same  as  after  other 
operations  and  injuries.  If  it  occtirs  (hiring  the  operation,  use  at  once 
the  extreme  Trendelenburg  position,  and  flood  the  peritoneal  ca\ity 
with  a  quart  or  more  of  normal  salt  solution,  0.(5  per  cent.,  at  a  tem- 
perature of  105°  F.,  and  complete  the  operation  as  soon  as  possible. 
After  the  operation  elevate  the  foot  of  the  bed.  Among  other  meas- 
ures for  the  treatment  of  shock  are  the  application  of  dry  heat  to  the 
surface;  the  hypodermic  administration  of  strychnine  sulphate  every 
four  hours  in  doses  of  one-thirtieth  of  a  grain  each ;  the  free  hypodermic 
use  of  whiskey,  at  least  four  drachms  every  hour;  the  hypodermic 
injection  of  two  grains  of  camphor  dissolved  in  ten  minims  of  sterilized 
olive  oil,  to  be  given  every  hour;  and  copious  high  rectal  enemas  of 
warm  normal  salt  solution,  to  be  retained  if  possible.  Shock  is  most 
apt  to  occur  when  considerable  blood  has  been  lost  during  the  opera- 
tion; whether  from  this  cause  or  not,  the  urgent  indication  is  to  fill 
the  blood-vessels,  and  thereby  increase  arterial  pressure.  See  Hypo- 
dermoclysis,  below.  Hypodermoclysis  as  described  helow  under  secondary 
hemorrhage  is  strongly  indicated. 

Secondary  Hemorrhage. — It  is  often  difficult  to  differentiate  hemor- 
rhage from  shock.  The  former,  if  post  operative,  is  usually  slow  and 
may  not  declare  itself  until  several  hours  after  the  operation.  The 
latter  more  commonly  begins  some  time  during  the  operation. 

Diagnosis. — The  symptoms  of  hemorrhage  are  well  known.  The 
patient  has,  perhaps,  rallied  well  from  the  operation,  with  good  pulse 
and  temperature.  Presently,  or  within  a  few  hours,  there  are  symp- 
toms of  approaching  collapse — /.  e.,  rapid,  thready  pulse,  subnormal 
temperature,  pallor,  sighing,  gaping,  and  cold  surface.  If  these  symp- 
toms appear,  the  presence  of  much  clotted  blood  in  the  drainage-tube, 
if  there  be  one,  may  clear  the  diagnosis.  The  gauze  drain  would  show 
a  stain  of  deeper  red  than  ordinary  blood-serum  should  make.  Both 
of  these  signs,  however,  may  fail.  If  there  is  no  drain,  one  often  may 
work  a  small  glass  female  catheter  through  the  wound  between  the 
stitches.  Hemorrhage  then  would  declare  itself  by  the  presence  of  clear 
blood  in  the  catheter. 

Treatment. — To  reopen  the  wound,  find  the  source  of  hemorrhage, 
apply  a  ligature  or  a  pressure-forceps,  sponge  or  wash  out  the  cavity, 
and  close  the  wound  with  the  patient  bordering  on  collapse,  is  indeed 


156 


GENERAL   PRINCIPLES 


a  serious  undertaking.  If,  however,  there  is  hemorrhage,  any  other 
attempt  to  check  the  bleeding  is  not  only  useless,  but  a  dangerous 
waste  of  time  as  well. 

Hypodermoclysis  after  Hemorrhage. — A  most  effective  means 
of  combating  the  results  of  hemorrhage  is  the  hypodermoclysis  injec- 
tion of  large  quantities  of  normal  salt  solution.  The  strength  should 
be  not,  as  generally  directed,  0.6  per  cent.,  but  about  0.8  per  cent. — 
i.  e.,  8  parts  in  1000.  An  even  teaspoonful  of  table  salt  in  a  pint  of 
water  is  a  safe  and  reliable  approximation  to  the  required  strength.    // 

Figure  77 


Apparatus  for  hypodermoclysis.  The  funnel  contains  twenty  ounces.  A  rubber  tube,  with  shut-off 
attached,  connects  it  with  a  Y-shaped  glass  tube.  Two  small  rubber  tubes  connect  this  with  aspirator 
needles  or  large  hypodermic  points.  The  injection  may  be  thrown  into  the  thighs,  abdominal  wall, 
or  under  the  breasts.     The  submammary  region  is  usually  selected. 


the  pulse  is  alarmingly  feeble  add  to  the  solution  ten  minims  of  adrenalin 
and  three  and  a  half  grains  of  calcium  chloride.  The  value  of  this  com- 
bination cannot  be  too  much  emphasized.  The  procedure  may  have 
to  be  repeated  every  six  to  eight  hours  for  days. 

The  technique  of  this  simple  and  valuable  treasure  is  as  follows: 
The  saline  solution  and  the  apparatus  for  its  injection  are  sterilized  by 
boiling.  The  solution  having  been  boiled,  is  now  cooled  to  the  proper 
temperature,  say  110°  F.  The  surface  through  which  the  needles  are 
to  be  introduced  is  sterilized,  and  the  needles,  as  shown  in  the  diagram, 


AFTER-TREATMENT  IX   MAJOR  OPERATIONS  157 

are  thrust  derply  into  thf  (rllular  tissue  uuder  the  skin.  The  solution 
Hows  from  tlie  bottle  or  funnel  hy  its  own  weii^ht.  An  elevation  of 
four  or  five  feet  is  necessary  to  make  the  fluid  How  freely.  Constant 
gentle  massage  over  the  injected  area  will  promote  the  distribution 
and  absorption  of  the  Huid.  Ten  or  fifteen  minutes  usually  will  suffice 
for  the  introduction  of  a  pint  of  solution.  The  apjiaratus  consists  of 
a  glass  funnel  attached  to  a  large  hypodermic  needle,  single  or  double, 
by  means  of  a  long  rubber  tube.  The  Huid  passes  rapidly  into  the 
eirculatit)n.  immediately  increasing  arterial  pressure;  the  ])rocedure 
gi\es  rise  to  little  or  no  pain.  It  is  sometimes  necessary,  after  an 
exhausting  hemorrhage,  to  inject  at  intervals  into  the  breasts  or  aixlomi- 
nal  wall  or  outer  surface  of  the  thighs  as  much  as  three  quarts  in  a 
single  day. 

The  prime  indication  to  increase  arterial  pressure  is  ordinarily  more 
safely  and  quite  as  ett'ectively  fulfilled  by  this  method  as  by  the  direct 
injection  of  blood  or  salt  solution  into  the  vessels.  When  the  loss  of 
blood  has  amoimted  to  between  one-fourth  and  one-half  of  the  entire 
quantity  in  the  body,  some  prefer  to  throw  the  solution  directly 
into  a  vein.  This  demands  the  greatest  care  in  asepsis  and  extreme 
precaution  against  the  introduction  of  air. 

High  rectal  enemata  of  salt  solution  are  useful,  but  less  rapidly 
effective  than  hypodermoclysis. 

Drop  Method  of  Salt  Water  Infusion. — If  not  very  immediate 
action  of  normal  salt  solution  is  desired,  one  may  use  with  great  satis- 
faction the  drop  method  of  infusion  into  the  rectum.  For  this  purpose 
the  apparatus  shown  in  Figure  77  should  be  modified  as  follows:  Sub- 
stitute a  small-caliber  rectal  tube  for  the  needles  and  introduce  this 
tube  high  into  the  rectum.  Suspend  the  funnel  on  some  fixture  which 
will  hold  it  steady  about  four  feet  above  the  patient.  Hang  a  fountain- 
syringe  bag  with  a  short  rubber  tube  above  the  funnel  in  such  a  way 
that  water  will  flow  from  the  bag  into  the  funnel.  Regulate  the  current 
to  a  drop-by-drop  supply  by  means  of  a  pressure-forceps  placed  on  the 
supply-tube,  so  that  the  solution  passing  drop  by  drop  into  the  bovrel 
will  run  at  the  rate  of  not  over  a  pint  in  an  hour.  In  my  own  practice 
this  method  largely  takes  the  place  both  of  hypodermoclysis  and  ordinary 
enemata  of  salt  solution.    It  may  be  continued  for  many  hours. 

The  hemorrhage  having  ceased,  the  subsequent  treatment  is  the 
same  as  that  for  shock.  If  food  is  not  tolerated  by  the  stomach,  rectal 
alimentation  should  be  used  every  four  hours.  A  good  combination 
for  this  purpose  consists  of  the  white  of  an  egg,  three  ounces  of  pep- 
tonized milk,  and  one  ounce  of  whiskey. 

Sepsis. — The  phenomena  of  sepsis  often  are  considered  under  the 
name  peritonitis.  There  are  two  varieties:  first,  plastic  or  adhesive; 
second,  exudative.  In  the  plastic  variety  adhesions  may  form  around 
the  diseased  area;  in  this  way  the  infection  may  be  shtit  oft'  from  the 
general  peritoneum  and  confined  within  narrow  limits.  In  the  exuda- 
tive variety  the  plastic  or  defensive  action  is  absent  or  inadequate,  and 
the  infection  therefore  spreads  throughout  the  peritoneum  and  sets  up 


158  GENERAL   PRINCIPLES 

rapid  and  fatal  blood-poisoning.  It  is  a  mistake  to  attribute  the  evils 
of  sepsis  to  the  associated  peritonitis.  The  inflammatory  process  is 
an  efi^ort  of  nature  to  protect  the  general  system  against  infection: 
if  plastic  and  adhesive,  it  may  succeed;  if  exudative,  it  usually  fails. 
It  is  the  infection  that  specially  endangers  life,  not  the  associated 
peritonitis,  which  may  or  may  not  save  it.  Sepsis,  then,  or  to  use  a 
better  term,  infection,  may  clinically  be  classified  as  follows: 

1.  Localized  infection. 

2.  General  infection. 

1.  Localized  Infection. — This  usually  finds  expression  in  the  form 
of  an  abscess  at  the  seat  of  the  operation.  It  may  be  around  an  in- 
fected pedicle,  suture,  or  ligature.  The  nidus  may  be  a  surface  laid 
bare  in  the  operation  and  not  covered  by  peritoneum,  or  it  may  be 
pathological  tissue  which  could  not  be,  or  at  least  was  not,  removed. 
Localized  infection  is  apt  to  declare  itself  a  few  days  after  operation. 
The  prognosis  is  usually  good. 

The  symptoms  are  those  of  septic  absorption:  rapid  but  usually 
strong  pulse,  variable  elevation  in  temperature,  localized  pain,  sweats, 
chilly  sensations,  with  little  or  no  tendency  to  collapse.  Examination 
usually  will  show  a  progressively  enlarged  swelling  situated  in  the  pelvis 
and  felt  usually  on  conjoined  examination.  Stitch-abscess  may  give 
rise  to  the  same  symptoms,  but  usually  in  less  degree. 

Treatment  is  simple  and  satisfactory.  Under  anaesthesia  the  abscess 
should  promptly  be  opened  and  drained.  The  drainage-channel  is 
usually  through  the  incision  by  which  the  peritoneum  was  entered  in 
the  original  operation — i.  e.,  through  the  abdomen  or  vagina.  If  a 
drainage-tube  is  already  in  the  wound,  there  may  be  spontaneous 
rupture  of  the  abscess  into  the  tube.  In  an  aggravated  case  it  is  some- 
times best  to  make  through-and-through  drainage  from  the  abdominal 
wound  to  the  vagina.    Rubber  tubes,  not  gauze,  are  best  for  drainage. 

In  case  of  stitch-abscess — that  is,  suppuration  in  the  line  of  the 
wound — the  sutures,  if  of  the  through-and-through  variety,  should  be 
removed,  if  of  the  buried  catgut  variety  they  should  be  left.  Any 
accessible  accumulation  of  pus  should  be  opened  with  a  blunt-grooved 
director  and  evacuated;  then  the  wound  should  be  treated  with  a  95 
per  cent,  alcohol  gauze  dressing,  the  gauze  being  changed  often  and 
kept  wet  with  the  alcohol. 

2.  General  Exudative  Infection  of  the  Peritoneum — i.  e.,  septic  perito- 
nitis, which  is  apt  to  declare  itself  very  soon  after  the  operation — is 
fatal.  Every  abdominal  surgeon  is  painfully  familiar  with  the  character- 
istic symptoms.  He  has  described  them  from  afar  as  one  may  discern 
the  dark  cloud  upon  the  horizon.  In  the  balance  betwee7i  hope  and  fear 
he  has  watched  the  anxious  face,  the  drawn  expression,  the  progressively 
rising  temperature,  the  nausea,  at  first  attributed  to  mmsthesia,  then  as 
this  subsides  the  vomiting  of  sepsis  which  takes  its  place,  the  frequent 
regurgilation  of  bile  mixed  with  blood  and  mucus  and  growing  darker 
and  darker.  He  has  recognized  the  gradual  failure  of  the  pulse,  first  weak, 
then  running,  then  thready  to  the  vanishing-point,  the  paretic  and  distend- 


AFTKU  TliKATMKXr   IS    MAJdh'  O/'A'AM  770.V.S'  loO 

iHf/  hoircl.i,  irliicli  nj'ii.s'i' to  act,  the  rajiid  rcspirdtidii.s-,  the  cold  c.rfmiiilirs, 
t/ir  stdniKj  I'jii's,  the  iridc  unstrils,  (ind,  /iinilli/,  ilir  iiirritdhic  colhtjj.sc. 

Trcdhnciif  is  listless.  Tho  syini)t()iii-<i;r()ii])  just  outlined  may,  how- 
ever, he  present  in  less  ^rave  cou(Utions,  anion<i  tliem  the  loeal,  eireum- 
scribed  infection  ahove  described.  Bowel  distension,  \'onutinfi:,  fe\er, 
and  rapid,  weak  i)ulse  may  also  be  due  to  causes  other  than  ^^eneral 
peritoneal  infection.  In  view  of  this  j)ossil)i]ity,  therefore,  active 
treatment  may  he  indicated.  See  especially  aciifc  dUataiion  of  the 
stomach  in  a  following  paragraph. 

The  first  effort  should  be  directed  to  the  movement  of  the  bowels. 
Try  calomel,  one-half  i:;rain  every  half-hour  until  the  })owels  have 
acted.  Let  this  be  followed,  if  necessary,  by  the  solution  of  citrate 
of  magnesium,  a  wine<i;lassfid  every  fifteen  minutes,  or  more  if  the 
stomach  will  tolerate  it.  In  obstinate  cases  a  single  soft  capsule  con- 
taining castor  oil  2  drachms  and  croton  oil  one-half  drop  will  be  found 
serviceable.  Copious  rectal  enemata  may  stimulate  the  bowels  to  act, 
or  at  least  to  expel  the  flatus.  The  enemata  may  be  of  stiff  Castile 
soapsuds,  with  a  drachm  of  turpentine  thoroughly  mixed  in  each  pint. 
It  may  be  a  mixture  of  glycerin,  Epsom  salt,  and  w^ater,  each  two  ounces, 
or  a  quart  of  olive  oil  or  linseed  oil.  A  large  enema  should  be  given 
slowly  through  a  long  rectal  tube  introduced  as  high  as  possible,  with 
the  patient  on  the  left  side.  The  muscular  walls  of  the-  bowel  in  this 
condition  are  generally  paretic;  hence  the  great  difficulty  in  stimulating 
them  to  contract  and  by  peristalsis  to  expel  their  contents. 

Whiskey,  strychnine,  camphor,  ammonia,  rectal  alimentation,  and 
other  supporting  measures,  as  described  for  the  treatment  of  shock, 
may  be  used  in  moderation.  Under  such  management  patients  wdth 
symptoms  like  those  of  general  peritoneal  infection  may  recover. 

Credes  ointment  of  argentum  colloidale,  one  drachm  a  day  thoroughly 
rubbed  in  for  two  to  tw'cnty  minutes,  and  intravenous  injections  of  a 
2  per  cent,  emulsion  of  argentum  colloidale  once  a  day  in  doses  of  15 
grains,  are  among  the  strongly  recommended  measures.  Antistrepto- 
coccic serum,  given  hypodermically  10  to  40  c.c.  a  day,  may  be  useful 
for  streptococcic  infection. 

The  free  use  of  powerful  toxic  drugs  as  a  routine  practice  is  deplor- 
able; desperate  conditions  do  not  necessarily  call  for  desperate  measures; 
these  drugs,  unless  used  with  the  best  judgment,  may  take  away  the 
only  remaining  chance  for  life  from  a  patient  already  overburdened 
with  the  toxa?mia  of  sepsis. 

Rapid  reopening  of  the  abdomen,  multiple  drainage,  and  Fowler's 
position  according  to  some  reports  has  been  successful ;  it  is  to  be  hoped 
that  these  cases  were  not  subjects  of  mistaken  diagnosis. 

Hysterical  Vomiting. — In  about  1  per  cent,  of  abdominal  sections 
the  operation  is  followed  by  vomiting,  frequent,  violent,  prolonged, 
and  exhausting.  The  nervous  depression  is  profound;  the  pulse  may 
rise  to  170  or  ISO  to  the  minute.  The  condition  may  continue  for 
several  days,  with  final  recovery,  or  may  pass  into  collapse.  The 
pathology  of  this  phenomenal  ner\'e-storm,  with  the  stomach  for  the 


160  GENERAL   PRINCIPLES 

storm-centre,  is  unexplained.  It  may  be  due  to  toxaemia,  or  to  irrita- 
tion similar  to  that  which  produces  the  vomiting  of  pregnancy.  The 
causes  are  widely  different  from  those  of  the  sepsis  above  described. 
There  is  little  or  no  fever;  the  temperature  may  be  subnormal,  as  in 
shock:  the  bowels  seldom  are  distended.  There  is  simply  colossal, 
almost  incessant,  vomiting,  sometimes  even  to  the  extent  of  fecal 
vomiting.  Starvation  and  the  violent  exertion  of  the  vomiting  soon 
exhaust  the  patient.  This  condition  should  be  carefully  distinguished  from 
acute  dilatation  of  the  stomach,  described  in  later  paragraphs  of  this  chapter. 

Treatment. — The  vomiting  sometimes  suddenly  ceases  without  ap- 
parent cause.  The  removal  of  the  sutures  or  of  a  drainage-tube  has 
been  followed  by  prompt  relief.  In  one  case  in  the  writer's  practice 
the  vomiting  promptly  and  permanently  ceased  upon  simply  reopening 
the  lower  end  of  the  abdominal  wound;  nothing  abnormal  was  found, 
and  the  wound  was  closed  immediately. 

The  diagnosis  once  made  to  the  exclusion  of  septic  peritonitis,  the 
treatment  is  simple  and  effective.  It  is  the  free  hypodermic  use  of 
morphine  in  doses  sufficient  to  allay  all  nervous  irritation,  to  induce 
sleep,  and,  above  all,  to  give  the  stomach  and  bowels  rest.  Under 
the  influence  of  morphine  food  is  retained,  and  in  two  or  three  days 
the  patient  recovers.  The  indication  also  is  for  hypodermic  injections 
of  strychnine,  one-sixtieth  of  a  grain  every  four  to  six  hours,  for  rectal 
alimentation  and  for  washing  out  the  stomach  through  a  stomach-tube. 

Acute  Dilatation  of  the  Stomach,  which  sometimes  occurs  in  acute 
infectious  diseases,  such  as  pneumonia  and  typhoid  fever,  is  an  occasional 
sequel  of  surgical  operations,  both  major  and  minor.  It  is  apt  to  come 
on,  if  at  all,  within  two  days  after  operation.  A  significant  associated 
factor,  carbonic  dioxide  toxaemia,  is  probably  due  to  cessation  of  what 
has  been  called  the  respiratory  function  of  the  alimentary  tract,  which 
for  some  reason  has  ceased  to  eliminate  carbon  dioxide.  The  primary 
characteristic  symptom  is  a  gradually  increasing  emesis  of  a  mixture 
of  rather  dark  fluid  with  brown-colored  streaks,  sometimes  called 
prune-juice  vomiting.  Unless  relief  is  promptly  given,  the  stomach 
rapidly  becomes  distended  with  this  fluid  and  the  bowels  become 
tympanitic  and  secondarily  profound  toxaemia  with  sometimes  septic 
peritonitis  follows.  The  condition  symptomatically  at  least  resembles 
exudative  infection  of  the  peritoneum,  already  described  as  a  fatal  dis- 
ease; it  is  often  difficult,  sometimes  impossible,  to  differentiate  between 
the  two  conditions.  In  dilatation  there  is  greater  predominance  or  early 
and  persistent  vomiting,  a  somewhat  less  early  disposition  to  distention 
of  the  bowel,  and  a  relatively  slower  development  of  high  temperature, 
like  the  so-called  hysterical  vomiting,  already  mentioned;  the  pulse- 
rate  may  increase  to  an  alarming  degree.  It  is  most  important  to  keep 
in  mind  clearl}-  the  predominant  and  alarming  early  symptom  by  which 
the  condition  may  be  recognized  early,  that  is,  the  so-called  prune- 
juice  vomiting,  streaked  with  very  dark  pigment. 

Treatment. — The  treatment  is  simple  and  in  the  majority  of  cases  brilli- 
antly successful ;  it  is  to  pass  the  stomach-tube  and  draw  off  the  accumu- 


AFTKl;    riiEATMEN'r   IS    MA.IOU  Ol' EliATIONS  Kil 

lated  contents  of  the  stoniadi,  then  wasli  out  tlic  stoniacli  tliorouj^^lily 
witli  a  1  percent,  aqueous  solution  of  sodium  bicarbonate,  continuing?  the 
Ia\'a,ii;e  until  the  sohition  returns  clear;  the  prirr  of  .s'lirccss  is  cxtreiiir 
lii/ildnrc  and  reptiilioii.s  of  the  Idrogc  a.v  soon  as  the  character istlc  vo)iiiiin[/ 
rciurns,  which  may  be  c\ cry  one.  two,  three,  or  four  hours.  The  sur- 
geon should  not  trust  tliis  la\aj;e  to  the  nurse  nor  to  his  assistant, 
unless  he  can  have  the  utmost  confidence  that  it  will  he  promptly  and 
efficiently  performed  on  the  first  reai)pearance  of  vomiting.  If  on 
account  of  spasm  of  the  (x^sophagus,  which  not  infre(iuently  occurs, 
the  stomach-tube  cannot  be  passed,  it  may  })e  necessary  to  withdraw 
the  contents  of  the  stomach  and  wasli  out  through  the  aspirator  needle, 
w  Inch  unhesitatingly  should  be  substituted  for  the  tube  if  occasion 
requires. 

Supplementary  to  the  lavage  already  outlined  in  the  ])receding 
paragraph,  it  may  be  essential  to  secure  action  of  the  bowels  by  means 
of  the  sulphate  of  physosiujmin,  grain  0.01,  which  may  be  repeated 
once  or  twice  at  intervals  of  two  or  three  hours.  If  the  character  and 
rapidity  of  the  pulse  so  indicates,  hypodermic  injection  of  camphor, 
'1  grains,  dissolved  in  sterile  olive  oil,  may  be  used  every  two  hours, 
or  digipuratum  or  digitalin  may  be  indicated. 

Obstruction  of  the  Bowels  as  a  post-operative  accident  is  not 
uncommon. 

Causes. — In  addition  to  non-surgical  causes  which  may  at  any 
time  be  present,  there  are  those  causes  that  result  directly  from  the 
operation.  The  bowel  may  be  bent  sharply  upon  itself — i.  e.,  knuckled 
so  as  to  make  occlusion  at  the  point  of  flexure.  If  at  the  same  time 
adhesions  form  at  or  neat  the  point  of  flexure,  immobilization  takes 
place,  the  bow^el  cannot  straighten  itself,  and  obstruction  is  established. 
Sometimes  a  part  only  of  the  circumference  of  the  bowel  is  constricted 
either  in  a  hernial  opening — Littre's  hernia — or  between  bands  of  ad- 
hesion. The  diverticulum  looks  like  a  nipple  as  it  protrudes  from  the 
convex  surface  of  the  intestinal  loop.  On  relie^'ing  the  constriction 
the  nipple  disappears,  leaving  a  deeply  indented,  dark-blue  ring.  This 
form  of  hernial  obstruction  is  partial,  and  therefore  less  severe  than 
when  the  bowel  is  occluded  entirely.  Vomiting  is  less  free  and  less  apt 
to  be  fecal.  Flatus  in  small  quantities  may  continue  to  pass.  The 
downward  passage  of  feces  is  not  always  wholly  interrupted. 

Clearly,  adhesions  are  more  apt  to  occur  between  surfaces  not 
covered  with  peritoneum;  hence  the  importance  of  careful  plastic 
work  during  the  operation  to  cover,  so  far  as  possible,  all  exposed 
surfaces. 

Diagnosis  and  Prognosis. — It  is  important  to  distinguish  mechanical 
obstruction,  due  to  kinking,  intussusception,  or  adhesions,  from  mere 
failure  of  the  paretic  bowel  to  act.  The  two  conditions  may  resemble 
one  another  so  closely  as  to  make  the  distinction  impossible.  Reverse 
peristalsis  and  consequent  fecal  vomiting,  a  common  symptom  of 
obstruction,  seldom  occurs  in  paresis.  The  bowel  may  be  paretic 
from  a  grave  cause  hke  septic  peritonitis,  or  from  some  trivial  cause. 
11 


162  GENERAL  PRINCIPLES 

The  diagnosis  is  the  same  as  for  obstruction  of  the  bowel  from  other 
causes.  Nausea,  vomiting,  first  of  bile,  finally  of  feces,  abdominal 
distension,  and  rapid  pulse  are  among  the  prominent  symptoms.  Peri- 
tonitis is  first  local  and  confined  to  the  afi'ected  part;  but  later  may 
become  general.  Death  usually  follows  within  a  few  days,  unless  the 
patient  is  relieved  by  surgical  means. 

Treatment. — Before  proceeding  to  the  dangerous  operation  of  re- 
opening the  wound  and  looking  for  the  cause  of  obstruction  an  attempt 
should  be  made  to  secure  relief  by  means  of  high  rectal  enemata  and 
position.  In  an  aggravated  case  of  apparent  mechanical  obstruction 
in  which  the  abdomen  is  distended  to  the  size  of  full-term  pregnancy 
and  strenuous  attempts  to  secure  action  of  the  bowels  by  means  of 
enemata  and  cathartics  have  failed,  the  following  measures  may  give 
prompt  relief:  (1)  croton  oil,  one-half  drop  to  one  drop;  (2)  a  hot 
stupe  of  25  per  cent,  turpentine  covering  the  entire  abdomen,  the 
dressing  over  the  wound  having  all  been  removed  in  order  that  the 
stupe  may  be  applied  directly  to  the  skin;  (3j  frequent  change  in  the 
position  of  the  patient,  especially  turning  on  the  abdomen.  It  is  most 
essential  to  distinguish  between  obstruction  from  shutting  off  the 
lumen  of  the  bowel  and  simple  failure  of  action  from  other  causes,  for 
in  actual  obstruction  cathartics  might  do  much  harm. 

The  diagnosis  of  mechanical  obstruction  once  established,  no  time 
should  be  lost  in  the  attempt  to  relieve  the  bowels.  If  the  ob.struction 
has  been  continuous  for  thirty  hours,  and  upon  reopening  the  abdomen 
the  operator  cannot  immediately  locate  the  cause  of  it  and  promptly 
open  the  way  through  it,  the  safer  treatment  would  be  to  establish 
an  artificial  anus,  even  though  a  later  operation  may  be  necessary 
to  restore  the  integrity  of  the  bowel  and  close  the  sinus. 

Obstruction  and  paresis  are  much  less  likely  to  occur  if  the  bowels 
have  been  relieved  thoroughly  of  feces  and  gas  before  the  operation. 
See  Preparatory  Treatment  in  Chapter  II. 

Sinuses. — The  localized  infection  described  in  a  preceding  para- 
graph commonly  subsides  on  drainage.  vSometimes  the  source  of  in- 
fection is  continuous;  then  the  drainage-track  becomes  a  sinus,  and 
may  continue  to  transmit  pus  until  the  infective  substance  is  removed. 
This  substance  is  usually  an  infected  ligature  or  intra-abdominal  suture 
which  refuses  to  be  cast  off.  It  may  remain  for  months  or  years  a 
continual  nidus  of  infection  and  suppuration,  or  may  at  any  time  come 
away.  Spontaneous  closure  of  the  sinus  upon  removal  of  the  infective 
substance  is  the  almost  invariable  rule.  If  not  spontaneously  thrown 
off,  such  ligatures  or  sutures  often  may  be  caught  and  fished  out  by 
means  of  an  instrument  acting  on  the  principle  of  a  crochet-needle, 
or  by  means  of  a  very  small  dull  curette.  Should  these  fail  and  the 
discharge  continue  for  a  number  of  months,  the  indication  is  to  cut 
down  and  remove  the  offending  cause.  The  operation  is  usually  simple 
and  relatively  safe.  An  incision  through  the  abdominal  wall  in  the 
track  of  the  original  wound  commonly^  enables  the  operator  to  dilate 
the  deeper  part  of  the  sinus  and  seize  the  ligature;  if  not,  the  adherent 


AFTER-TREAT M EXT   IS    MAJOR  Ol'EIiATIO.XS  103 

viscera  nia\'  \>v  si'j)aratc(l  carefully  until  tlic  nidus  is  reached  and 
removed. 

Lou^-coiitinued  suj)|)urati()n  is  a  reproacli  to  the  sur<ieoii;  it  is  annoy- 
ing, irritatini;,  and.  e\en  though  slight,  tends  to  produce  degeneration 
of  the  kithieys  and  other  important  organs;  hence  tiie  necessity  of 
efficient  methods  for  the  prevention  of  it  or  for  removal  of  the  offending 
source. 

Prevention. — The  use  (jf  absorbable  catgut  sutures  and  ligatures 
which  may  be  sterilized  absolutely — see  Chapter  II. — is  a  most  satis- 
factory preventive.  Silk,  silkworm-gut,  metallic,  and  other  non- 
absorbable sutures  and  ligatures,  for  the  reasons  indicated,  are  not 
generally  advised  in  peritoneal  surgery. 

Fecal  Fistula. — The  bowel  during  an  operation  may  be  opened 
or  so  injured  that  an  opening  is  liable  to  occur  later.  In  either  event 
the  injury  should  be  repaired  before  closing  the  abdomen.  In  a  small 
proportion  of  such  cases  the  sutures  fail,  or  the  bowel  opens  at  some 
unsuspected  point.  The  result  usually  is  local  infection,  as  already 
described,  followed,  if  the  patient  survives,  by  a  fecal  fistula  with 
discharge  of  the  bowel  contents  through  a  sinus  in  the  wound.  The 
fistula,  in  a  maj  ority  of  cases,  if  left  a  few  days,  weeks,  or  months, 
will  close  spontaneously.  Closure  is  usually  more  prompt  in  sinuses 
through  the  vaginal  than  through  the  abdominal  wound.-  The  explana- 
tion of  this  may  be  that  the  sinus  is  shorter  and  the  vaginal  wound 
less  accessible,  and  therefore  less  tampered  with  by  the  surgeon.  If 
the  fistula  does  not  finally  heal,  an  operation  for  the  closure  of  it  may 
be  necessary. 

Urinary  Fistula  follows  the  same  general  laws  as  fecal  fistula.  The 
former  seldom  occurs  except  when  the  bladder  or  the  ureter  has  acci- 
dentally been  opened  in  the  operation  and  the  sutures  for  its  closure 
have  failed.  The  presence  of  the  fistula  is  recognized  by  the  appearance 
of  urine  in  a  sinus  opening  through  the  wound.  The  treatment  is  to 
introduce  a  self-retaining  catheter  and  keep  it  in  the  urethra  until 
the  fistula  closes.  Secondary  sutures  seldom  are  required.  A  ureteral 
opening  is  more  serious  and  requires  special  operative  measures. 

Ventral  Hernia. — The  chief  causes  of  ventral  hernia  in  connection 
with  abdominal  operations  are  the  drainage-tube — see  Drainage — 
improper  closure  of  the  wound,  and  want  of  proper  support  to  the 
abdomen  by  elastic  bandages  during  the  first  few  months  after  the 
operation.  The  longer  the  incision  and  the  thinner  the  abdominal 
wall  the  greater  the  need  of  the  bandage;  incisions  not  more  than  two 
inches  long,  if  properly  closed,  seldom  require  it.  The  treatment  is 
to  reopen  the  abdomen  through  or  near  the  old  cicatrix,  split  the 
sheaths  of  the  recti  muscles,  and  reunite  the  wound  as  already  directed 
for  ordinarv  closure  of  an  abdominal  wound. 


CHAPTER   IX 

THE  RELATIONS  OF  DRESS  TO  THE  DISEASES  OF 

WOMEN  1 

Manner  of  living,  environment,  food,  sleep,  work,  rest,  recreation, 
exercise,  and  clothing  necessarily  must  have  a  determinate  influence 
on  the  prophylaxis  and  cure  of  disease.  The  gynecologist,  therefore, 
who  gives  to  this  subject  its  true  weight  will  stand  upon  a  decided 
vantage-ground  over  that  one  whose  resources  are  limited'to  drugs,  local 
treatment,  and  operative  measures.  One  of  the  most  serious  of  all 
obstacles  to  the  prevention  and  cure  of  the  diseases  of  women  is 
fashion  in  dress. 

So  long  as  sensible  dress  appears  eccentric  and  excites  ridicule 
women  will  adhere  to  the  prevailing  modes  and  will  therefore  be 
hampered  not  only  in  the  pursuit  of  recreation  and  exercise  but  also 
in  the  performance  of  the  more  essential  physiological  functions.  Under 
such  conditions  fashion  must  continue  to  prevail  against  strong  nerves, 
powerful  muscles,  and  robust  health.  As  soon  as  the  girl  passes  from 
the  nursery  to  the  drawing-room,  and  the  dress  of  childhood  is  changed 
for  the  conventional  dress  of  fashion,  some  of  the  evils  of  what  we  call 
civilization  become  manifest.  She  can  neither  walk,  run,  nor  even 
breathe  without  embarrassment.  The  fact  that  woman  has  endured 
and  survived  the  tyranny  of  dress  for  centuries  without  more  serious 
results,  says  Emmet,  is  convincing  proof  of  her  power  of  endurance. 

The  prevention  and  cure  of  the  diseases  peculiar  to  women  require 
the  fulfilment  of  three  principal  conditions  in  dress: 

1.  Even  distribution  for  uniform  protection  against  cold  and  wet. 

2.  Freedom  from  waist  constriction. 

3.  Freedom  from  traction. 

1.  Even  Distribution — Uneven  distribution  is  conspicuous  in  the 
prevailing  modes  of  dress.  The  undergarments  are  usually  of  cotton 
or  other  light  material  and  are  often  sleeveless  and  low  in  the  neck. 
Numerous  skirts  hang  about  the  lower  extremities  and  give  them 
relatively  little  protection.  The  outer  garments  are  usually  of  thin 
material,  and,  according  to  the  caprice  of  fashion,  may  or  may  not 
cover  the  arms,  neck,  and  upper  part  of  the  bust.  The  headgear  is  use- 
less for  protection.  The  feet  often  are  held  in  the  vice-like  grasp  of 
thin,  high-heeled  coverings  which  more  resemble  stilts  than  shoes. 
They  fail  to  protect  the  woman  against  cold  and  prevent  free  exercise. 
In  contrast  with  such  inadequate  protection  for  the  upper  and  lower 

1  The  writer,  in  this  presentation  of  the  subject,  has  adapted  freely  from  the  works  of  Robert  L. 
Dickinson,  of  Brooklyn,  and  J.  H.  Kellogg,  of  Battle  Creek. 

(164) 


THE  RELATJOXS  OF  DRESS   TO   THE  DISEASES  OF    WOMEN     165 

extremities,  the  waist  and  hips  are  swathed  and  compressed  in  a  "torrid 
zone"  of  whalebone,  corsets,  belts,  steels,  skirts,  and  other  cumber- 
some material. 

2.  Waist  Constriction  comes  chiefly  from  the  corset,  which  not  only 
constricts  tiic  waist,  but  also  dislocates  the  thoracic  viscera  upward 
and  the  abdominal  viscera  downward.  It  restrains  the  abdominal 
and  dorsal  muscles,  and  may  cause  them  to  atrophy  from  disuse.  It 
prevents,  by  its  stiffness,  the  undulatory  movements  of  the  abdominal 
walls  and  restricts  peristalsis. 

Normal  breathincj  requires  the  lungs  to  be  expanded  in  all  directions, 
and  is  therefore  not  costal  nor  abdominal,  but  a  combination  of  both. 
Waist  constriction  immobilizes  the  abdomen,  and  thereby  prevents 


The  left-hand  figure  is  corset  deformed,  with  the  thoracic  and  abdominal  organs  displaced.    The  right- 
hand  figure  is  normal,  with  the  thoracic  and  abdominal  organs  in  place. 


abdominal  breathing.  This  involves  a  loss  in  lung-power  which  cannot 
be  supplied  by  any  compensatory  increase  in  costal  breathing.  ^Nlore- 
over,  the  diaphragm  from  upward  pressure,  and  the  pelvic  floor  from 
downward  pressure,  are  rendered  inactive  and  atrophic,  and  are  thereby 
unable  to  make  their  upward  and  downward  movements  which  nor- 
mally should  be  transmitted  to  the  abdominal  and  pelvic  viscera. 
The  physiological  importance  of  these  respiratory  movements  is  very 
great.  They  are  a  sort  of  natural  massage.  The  descent  of  the  dia- 
phragm with  each  inspiration  increases  pressure  in  the  abdominal  cavity 
and  lessens  that  in  the  chest.  The  reverse  of  this  occurs  with  expiration. 
Alternating  pressure  and  relaxation  upon  the  blood-  and  lymph- 
vessels  secure  free  circulation.  Alternating  contraction  and  relaxation 
of  the  muscular  bundles  of  the  uterine  ligaments  and  of  the  other 


166  GENERAL  PRINCIPLES 

elastic  and  muscular  parts  of  the  pelvic  floor  serve  to  maintain  their 
normal  nutrition  and  tone.  Alternating  rest  and  motion  are  essential 
to  the  health  of  the  organs  and  their  supports;  Avaist  constriction  im- 
mobihzes  them  and  stops  their  physiological  movements.  The  pelvic 
veins  empty  into  the  greatest  area  of  corset  pressure;  the  long  and 
perpendicular  column  of  blood  of  this  area  is  by  such  pressure  dammed 
back  upon  the  pelvic  organs,  especially  upon  the  ovaries.  The  con- 
sequence is  passive  congestion,  an  unfailing  source  of  disease.  Even 
the  loosely  worn  corset  excites  great  downward  pressure  whenever  the 
woman  stoops  forward,  as  she  must  do  in  sitting  and  rising.  Sewing- 
women,  clerks,  writers,  and  students,  who  wear  corsets,  are  especially 
subject  to  this  evil.^ 

The  garter  is  injurious  from  its  tendency  to  obstruct  the  venous 
circulation  in  the  legs. 

3.  Freedom  from  Traction. — The  abdominal  and  dorsal  muscles 
and  the  hips  have  to  carry  the  weight  of  numerous  skirts  and  such 
other  garments  as  usually  oppress  that  area.  In  the  effort  to  sustain 
this  weight  the  muscles  become  permanently  tired,  lose  their  tonicity, 
and  are  powerless  to  prevent  a  still  further  increase  of  downward 
pressure  upon  the  pelvic  floor  and  pelvic  organs. 

To  compare  ordinary  modes  of  dress  wdth  those  which  give  freedom 
of  motion,  "one  has  only  to  look  at  a  lot  of  girls  on  the  way  to  the 
gymnasium,"  said  a  Vassar  teacher.  "They  drag  along;  they  have 
no  spirit  nor  spring  in  them;  they  are  in  their  ordinary  clothes.  Look 
at  the  same  set  coming  on  the  gymnasium  floor  in  their  light  toggery; 
they  skip  and  dance  and  run  in  the  liberty  of  unrestrained  and  un- 
trammelled motion;  they  are  different  beings." 

In  laying  aside  waist  constriction  avoid  half-way  measures,  such  as 
loosening  the  corset  or  substituting  the  so-called  health-waist,  which 
too  often  is  only  an  aggravated  form  of  corset.  Lea\ang  off  the  corset 
altogether  and  retaining  the  numerous  skirts  with  their  bands  and 
belts  to  drag  upon  the  waist  and  hips  rather  increase  than  lessen  the 
evil.  The  only  judicious  compromise  is  temporary  support  by  means 
of  a  suitable  waist  having  little  or  no  stiffness,  which  shall  cover  the 
shoulders,  and  upon  which  skirts,  drawers,  and  other  garments  may 
be  buttoned,  so  that  their  weight  may  be  distributed  over  the  shoulders. 
This  should  be  worn,  if  at  all,  only  during  the  period  of  aggravated 
weakness,  especially  weakness  of  the  back,  which  follows  the  with- 
drawal of  the  corset  and  continues  until  the  weakened  abdominal 
muscles  have  regained  their  tone. 

The  conventional  dress  has,  until  recently  at  least,  consisted  of 
nine  garments — four  hanging  from  the  shoulders  and  five  from  the 
waist,  namely: 

1.  Undershirt. 

2.  Chemise. 

3.  Corset-cover. 

1  Adapted  from  R.  L.  Dickinson.    Haie's  System  of  Practical  Therapeutics,  vol.  iii,  pp.  7.32,  7.3.3. 


Till':    RELATIOSS  OF   Dh'KSS   TO    TllE   DISEASED  OF    WOMES      1(17 


4. 

Dress  waist. 

."). 

riidfrdrawiTs. 

(i. 

White  drawers, 

7. 

Corset. 

S. 

Flannel  skirt. 

9. 

Dress  skirt. 

Cou 

nting  eaeli  hand 

about 

tlie  waist;  and 

as  two  thicknesses,  these  make  seventeen  layers 
allowing  twenty-five  inches  as  waist  circumfer- 
ence, these  seventeen  layers  if  joined  end  to  end  would  make  a  ban(hi^e 
thirty-four  feet  long. 

Hygienic  dress  requires  four  garments,  namely: 

1.  Union  undergarment. 

2.  Equestrienne  tights. 

3.  Muslin  waist  and  skirt. 

4.  Dress  in  one  piece,  or  so  made  that  its  principal  weight  may 

be   distributed   over   the   shoulders,   bust,   and   hips.     This 
makes  four  layers  about  the  waist. 

1.  The  union  undergarment  is  a  union  of  the  undershirt  and  drawers 
in  one  piece;  the  open  stride  is  supplied  with  the  broad  flap,  as  a  pro- 
tection to  the  external  genitalia  and  to  guard  the  other  garments  from 
their  secretions.  The  material  of  the  suit  may  be  silk,  wool,  or  cotton, 
or  any  mixture  of  these.  In  winter  it  should  be  heavy,  with  high 
neck  and  long  sleeves,  and  should  reach  to  the  ankle.  In  summer  it 
may  be  lighter,  with  lower  neck  and  short  sleeves,  and  should  reach 
to  the  knee. 

2.  The  equestrienne  tights  are  the  substitute  for  the  heavy  woollen 
petticoat,  and  are  designed  for  outdoor  use  in  winter.  They  reach 
from  waist  to  ankle,  corresponding  to  the  man's  trousers. 

3.  The  muslin  skirt  and  waist  often  are  made  in  one  piece,  but 
there  are  practical  advantages  in  making  them  separate.  The  waist, 
if  separate,  should  reach  well  down  o\er  the  hips,  and  the  skirt,  made 
without  band,  should  be  buttoned  to  it.  The  open  stride  of  women's 
garments  is  a  great  source  of  infection,  since,  in  conjunction  with  the 
dust-sweeping  skirts,  it  exposes  the  external  genitals  to  the  entrance 
of  dust  and  other  fine  particles,  which  are  always  irritating  and  often 
the  vehicle  of  infectious  bacteria.  Closed  muslin  drawers  are  there- 
fore desirable  as  a  means  of  protection,  and  these  also  may  be  buttoned 
to  the  waist. 

4.  The  dress  may  be  in  one  piece,  after  the  "princess"  pattern; 
or,  if  in  two  pieces,  the  skirt,  unless  too  heavy,  may  be  attached  to 
the  waist  with  hooks,  in  which  case  its  lining  may  be  continued  over 
the  shoulders  in  the  form  of  a  carefully  fitted  skeleton  waist. 

The  garments  just  described  may  be  modified  in  many  ways  to  suit 
individual  taste  and  changing  fashion,  but  the  essential  principle  must  be 
observed,  viz.,  uniform  distribution,  freedom  from  undue  weight  and 
traction,  and  freedom  from  constriction.  Light  whalebones  may  be 
useful  in  the  waist-seams  for  very  stout  women  with  pendulous  breasts. 
Proper  dress  and  consequent  freedom  of  motion  will  stimulate  the 


168  GENERAL  PRINCIPLES 

woman  to  outdoor  exercise  and  indoor  gymnastics,  which,  if  followed 
with  system  and  perseverance,  usually  will  give  normal  tone  to  the 
abdominal  and  thoracic  muscles  and  normal  firmness  to  the  breasts. 
Artificial  support,  therefore,  except  in  aggravated  cases,  is  to  be 
discouraged. 

Union  undergarments  of  all  grades  and  descriptions,  adapted  to  the 
needs  and  circumstances  of  all  classes,  now  may  be  found  in  the  shops. 
Economy,  health  comfort,  and,  to  the  properly  educated,  sense,  beauty, 
all  combine  on  the  side  of  proper  dress.  It  is  marvellous  that  the 
monstrosities  of  fashion  have  overshadowed  so  completely  the  natural 
beauty  of  form  and  figure.  From  the  standpoint  of  beauty  shall  we 
choose  the  natural  lines  of  the  body  or  the  artificial  lines  of  the  corset, 
the  garment  fitted  to  the  woman  or  the  woman  fitted  to  the  garment? 
Imagine  the  attempt  to  add  to  the  dignity  of  the  lion  or  to  the  beauty 
and  grace  of  the  greyhound  by  the  use  of  artificial  means  to  change 
the  natural  lines  of  their  bodies.  Throwing  aside  the  all-controlling 
bias  of  fashion,  who  shall  say  that  the  woman  is  so  inferior  to  the 
lower  animals  in  form  and  figure  that  she  must  be  taken-in  in  some 
places  and  let-out  in  others?  In  this  connection  the  words  of  Herbert 
Spencer  have  peculiar  force:  "Nature  is  made  better  by  no  mean, 
but  Nature  makes  that  mean;  over  that  art  which  you  say  adds  to 
Nature,  is  an  art  that  Nature  makes." 


PART  IT 

INFECTIONS   INFLAMaiATIOXS,  AND 
ALLIED  DIS0KDER8 


CHAPTER   X 


GENERAL  CONSIDERATIONS  OF  INFECTION  AND  INFLAM- 
MATION OF  THE  REPRODUCTIVE  ORGANS 

IxFECTiox  of  any  one  of  the  reproductive  organs  is  apt  to  be  asso- 
ciated with  similar  infection  of  a  part  or  all  of  the  others;  for  this 
reason  an  intelligent  consideration  and  satisfactory  explanation  of  the 
morbid  process  in  any  one  organ  may  necessitate  a  study  of  infection 
in  the  pelvic  organs  as  a  whole.  The  distinction  between  infection  and 
inflammation  is  of  the  greatest  practical  importance. 


Definition   of   Infecton 

Infection  is  that  condition  in  which  pathogenic  bacteria  have  gained 
access  to  a  region,  and  either  mechanically  or  by  means  of  their  products, 
disturbed  its  functions.  These  media  are  capable  of  being  transmitted 
to  other  parts  and  other  individuals.  The  organisms,  unless  arrested, 
are  prone  to  multiply  rapidly,  to  invade  new  territory,  to  transmit 
themselves  and  their  toxic  products  to  the  general  circulation,  and  to 
destroy  or  seriously  endanger  the  1  fe  of  the  patient. 


Definition  of  Inflammation 

Inflammation  is  nature's  method  of  restricting  the  advance  of  an 
infection;  it  is  characterized  by  a  succession  of  changes  as  follows:  first, 
localization  of  bacteria,  giving  rise  to  irritation;  second,  consequent 
dilatation  of  the  surrounding  arterioles  and  slowing  of  the  blood  stream; 
third,  migration  of  leucocytes  through  the  vessel  walls — diapedesis — 
into  the  infected  area.  A  process  of  seroplastic  infiltration  associated 
with  blood  stasis  thus  is  established  and  a  limiting  wall  formed  around 
the  infected  space.   The  classical  phenomena  of  heat,  redness,  pain,  and 

(169) 


170      INFECTIONS,   INFLAMMATIONS,   AND   ALLIED   DISORDERS 

swelling  now  are  present.  In  view  of  these  facts,  inflammation  is  not 
really  the  disease,  but  an  effort  to  limit  the  disease.  The  almost 
universal  use  of  the  word  inflammation  to  signify  the  disease  makes 
it  difficult  in  the  description  of  the  morbid  processes  to  conform  to  the 
ideas  above  expressed.  The  attempt  will  be  made,  however,  to  use 
the  two  words  infection  and  inflammation  in  their  proper  relations. 


Etiology  of  Infection  and  Inflammation 

It  is  important  to  remember  that  the  study  of  a  morbid  process  in 
an  organ  or  group  of  organs  is  simply  the  study  of  their  anatomy  and 
physiology  as  modified  by  that  process.  The  inflammatory  process 
has  been  defined  as  the  reaction  which  living  tissue  exhibits  to  morbid 
irritation.  This  definition  being  correct,  two  conditions  must  be 
essential  for  the  development  of  infection  and  inflammation :  The  soil 
must  be  prepared  and  ready  to  react  to  the  morbid  irritation.  Speaking 
clinically,  tissue  which  has  the  power  to  resist  irritation  and  to  hold 
it  within  physiological  bounds  will  not  inflame.    There  must  then  be: 

1.  Favoring  conditions. 

2.  Exciting  causes. 

1.  Favoring  Conditions. — Among  fhe  general  favoring  conditions  are 
various  so-called  diatheses,  such  as  gout,  rheumatism,  anaemia,  diabetes, 
litheemia,  and  cholsemia,  which  act  as  predisposing  causes  of  infection 
in  the  pelvic  organs,  but  the  exact  relation  which  they  have  to  the 
infection  is  somewhat  speculative. 

Local  favoring  conditions  are  apparent  in  the  anatomical  and  physio- 
logical arrangement  of  the  pelvic  organs.  The  genital  tract,  from 
the  vulva  to  the  peritoneum,  is  an  open  canal,  patent  to  the  atmosphere 
below  and  terminating  above  in  the  free  open  ends  of  the  Fallopian 
tubes.  It  is  not  only  open  to  such  microbic  germs  as  abound  in  the 
air  and  penetrate  everywhere,  but  is  also  a  place  of  deposit  for  virulent 
bacteria. 

Rupture  of  the  capillary  vessels  of  the  endometrium  in  menstrua- 
tion and  of  the  Graafian  folHcles  in  ovulation,  although  physiological, 
results  in  solution  of  continuity  and  in  hemorrhage,  and  is  therefore 
traumatic.  These  traumatisms  and  the  menstrual  engorgement  of 
the  pelvic  organs  under  healthy  conditions  pass  by  with  little  or  no 
discomfort;  but  if  some  morbid  irritation  upset  the  normal  balance 
of  nutrition,  the  menstrual  congestion  may  become  pathological  and 
may  be  the  first  stage  of  an  inflammation.  Morbid  congestion,  though 
less  frequently,  also  may  be  set  up  in  the  intermenstrual  period  inde- 
pendently of  the  menstrual  congestion. 

In  addition  to  the  physiological  traumatisms  already  mentioned, 
the  traumatisms  of  parturition,  of  abortion,  of  improper  local  treat- 
ment, and  of  operations  still  further  open  the  way  for  the  entrance 
of  infection.  Violent  coitus,  masturbation,  the  careless  use  of  the 
unclean    catheter,    and     syringe   or   douche-point,    impure  water    in 


IXFECT/OXS   or    Till-:    REI'UODICTIVK  ORCASS  171 

hatliiiiu',  and  soiled  linen  in  the  toilet  are  some  of  the  means  hy 
wliieh  ^•oiiorrhceal,  sv|)hihtie,  and  other  infections  may  de\ch)|)  in  the 
genital  tract. 

'I'he  eoHfiVstions  of  nteroucstation,  |)artnrition,  and  the  pnerperinm 
are  sj)eeially  perilous;  hence  infection  of  the  puerperal  woman  is  \'ery 
(lestructixe.  Decomposed  secretions  and  the  products  of  fatty  degen- 
eration from  involution  and  from  the  menopause  favor  the  develop- 
ment of  ])athogenic  microbes.  Tumors,  displacements,  tight-lacing, 
and  constipation  are  among  the  common  local  predisposing  causes  of 
m()ri)id  congestion  and  consequently  of  infection  in  the  ])el\-is.  Clearly 
the  favoring  conditions  abo^■e  outlined  contribute  to  the  preparation 
of  the  soil  for  infection. 

2.  The  Exciting  Causes  comprise  agents  that  ha\e  the  power  to 
produce  and  to  maintain  morbid  irritation.  Greatly  preponderating, 
at  least  among  these,  are  tiie  pathogenic  bacteria.  The  extent  to  which 
inflammation  may  be  produced  by  irritants  of  non-bacterial  origin 
without  the  presence  of  any  bacteria  whatever  is  largely  a  laboratory 
question,  and  is  not  fully  settled.  Among  the  pathogenic  microbes 
often  found  in  the  genitalia  are  the  staphylococci  and  streptococci 
of  suppuration,  bacillus  tuberculosis,  bacillus  coli  communis,  and  the 
pneumococcus.  Bladder  parasites  and  the  saprophytes  from  the  rectum 
and  colon  have  easy  access  to  the  genitalia.  See  Chapter  II,,  on  Anti- 
septics and  Asepsis.  The  bacillus  coli  communis  lives  in  acid  media, 
and  can  thns  easily  pass  through  the  acid  secretion  of  the  \'agina  to 
the  uterus. 

Among  the  exciting  causes  the  gonococcus  should  have  very  special 
consideration.     See  Gonorrhoea!  Vulvo\aginitis  in  Chapter  XL 


Pathology  and  Course   of  Infection  and  Inflammation 

Bacterial  invasion  and  consequent  infection  may  spread  and  in- 
volve any  or  all  of  the  genito-urinary  organs  by  either  or  both  of  two 
routes : 

1.  By  continuity  of  mucosa. 

2.  By  the  lymphatics  or  blood-vessels. 

1.  Infection  by  Continuity  of  Mucosa. — The  course  is  usually  up- 
ward from  the  vulva  or  vagina,  through  the  uterus  and  Fallopian  tubes 
to  the  ovaries  and  peritoneum,  or  through  the  urethra,  bladder,  and 
ureter  to  the  kidneys.  The  numerous  glands  of  the  vulva  are  strong- 
holds where  the  infection  may  intrench  itself  and  whence  a  constant 
supply  may  find  its  way  to  the  organs  above. 

The  vagina,  advantageously  covered  with  pavement  epithelium,  is 
relatively  smooth,  like  skin,  and  is  supplied  with  an  acid  secretion. 
Bacteria,  accordingly,  find  lodgement  there  less  easily  than  in  the 
vulva.  ^Moreover,  the  acid  medium  unfavorable  to  the  growth  of 
about  9  per  cent,  of  all  pathogenic  microbes  makes  the  vagina  a  barrier 
difficult  to  pass. 


172     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

The  uterus,  although  protected  by  the  above  anatomical  conditions 
of  the  vagina,  is  itself  especially  vulnerable  on  account  of  the  loose 
arrangement  and  thinness  of  the  epithelial  covering,  the  villous  net- 
work of  the  arbor  vitse  of  the  cervix,  the  confluence  and  ramifications 
of  the  glands,  and  the  richness  of  the  periglandular  and  perivascular 
network.  By  reason  of  these  conditions  the  cervix  uteri  is  adapted 
to  receive,  retain,  and  distribute  infection.  Were  it  not  for  the  mus- 
cular constriction  at  the  external  and  internal  ora  and  the  uterotubal 
constrictions  the  frequency  of  infection  of  the  endometrium  would  be 
much  greater. 

The  Fallopian  tubes  are  embryologicall}'  and  anatomically  continuous 
with  the  uterus;  they  are,  in  fact,  a  part  of  it,  and  subject  to  the  same 
causes  of  infection.  The  ovaries 'and  pelvic  peritoneum,  in  direct 
communication  with  the  tubes,  may  receive  infection  from  below. 
Infection  by  continuity  of  mucosa,  however,  although  usually  from 
below,  does  not  always  come  from  that  direction;  it  may  reach  the 
ovaries  and  pelvic  peritoneum  from  above,  and  descend  through  the 
tubes,  uterus,  and  vagina  to  the  vulva.  Tubercular  infection,  for 
example,  usually  goes  in  this  direction.  Gonorrhoea  usually  takes  the 
upward  course. 

2.  Infection  by  the  L3rmphatics  and  Blood-vessels  is  undeniable 
in  puerperal  women.  The  traumatism  of  parturition,  often  very  ex- 
tensive all  the  way  from  the  uterus  to  the  vulva,  may  open  wide  the 
door  for  infection  to  be  transmitted  by  the  vessels.  The  destructive 
influence  of  the  infection — i.  e.,  phlebitis  and  lymphangitis — on  the 
vessels  themselves  may  impair  seriously  and  permanently  the  nutri- 
tion of  all  the  pelvic  organs. 

It  is  believed  commonly  that,  except  in  puerperal  cases,  infection 
travels  by  continuity  of  mucosa  and  not  by  lymph-  and  blood-vessels 
in  the  deeper  structures.  It  is  clear,  however,  that  since  infection, 
as  is  proved  by  the  bubo,  often  is  transmitted  by  way  of  the  lymph- 
vessels  to  the  inguinal  glands,  it  may  travel  also  by  way  of  the  lymph- 
vessels  a  much  shorter  distance,  from  the  vagina  or  cervix,  to  the  par- 
ametria and  Fallopian  tubes.  This  reasoning  by  analogy  has  been 
verified  by  experiment.  Some  observers,  notably  Lucas-Championniere,i 
maintain  that  this  is  the  more  common  mode  of  infection.  Wertheim, 
from  experimental  investigation  on  white  mice,  rabbits,  dogs,  and 
guinea-pigs,  concludes  that  gonococcus  infection  can  pass  through 
pavement  epithelium  and  connective  tissue  so  as  to  reach  the  deeper 
lymphatic  and  vascular  channels,  and  be  carried  by  them'  from  the 
vagina  or  cervix  to  the  ovaries,  tubes,  and  peritoneum,  producing  thus 
ovaritis,  salpingitis,  and  peritonitis.  Giglio^  also  experimentally 
demonstrated  that  infection  may  travel  from  the  vagina,  cervix,  and 
bladder  to  the  broad  ligaments  and  may  produce  extratubal  pelvic 
abscess.     He  maintains  that  infection  by  the  vessels  is  more  frequent 

1  Paris  Surgical  Society  Transactions,  December,  1888.  New  York  Medical  Journal,  ^March  22, 
1890. 

2  Giglio.     Annalio  di  Obstetricia  e  Ginecologia,  May  and  June,  1893. 


INFECTIONS  OF  THE  REPRODUCTIVE  ORGANS  173 

than  by  continuity  of  surt'acr.  When  the  latter  occurs  lie  asserts,  hut 
without  proof,  that  it  is  more  commonly  in  the  descending  order  from 
the  tubes  to  the  uterus. 

Continuous  infection  does  not  always  mark  the  course  of  the  bacteria 
through  the  vessels;  hence  the  tubes  may  suppurate  and  the  ligaments 
and  ovaries  go  free.  When,  however,  infection  tra\els  by  way  of 
the  mucosa  continuous  inflammation  is  usual,  though  not  invariable. 

Infection  by  the  veins  is  especially  common  in  puerperal  cases.  It 
often  has  produced  general  septicaemia  and  pytemia  through  very 
slight  lesions.  The  arteries  also  may  carry  infection.  This  is  pro\ed 
by  the  fact  that  bacteria  have  been  found  in  places  where  they  must 
have  been  carried  by  the  centrifugal  circulation;  for  example,  the 
gonococcus  in  the  knee-joint.'  Hetero-infection  of  the  genitalia^ — 
i  e.,  infection  from  without — is  not  the  invariable  rule.  Diseased 
extrapeKic  organs  may  send  their  germs  by  way  of  the  lymphatics  or 
blood-vessels,  and  produce  secondary  infection  of  the  pelvic  peri- 
toneum, ovaries,  tubes,  and  other  genitalia.  Tubercular  infection  of 
the  tubes,  secondary  to  that  of  the  lungs,  is  a  familiar  example. 

Experiment  and  clinical  observation  also  show  that  both  puerperal 
and  non-puerperal  infection  may  travel  by  blood-vessels,  by  lymph- 
channels,  and  by  continuity  of  surface.  The  relative  frequency,  how- 
ever, of  these  modes  of  transmission  is  a  matter  of  speculation.  Prob- 
ably the  route  by  continuity  of  surface  is  really  a  superficial  lymph- 
route — that  is,  the  infection  may  travel  along  the  lymph-channels  of 
the  mucosa. 


Classification  of  Infection  and  Infiammation 

Let  us  now  raise  a  question  relative  to  the  looseness  and  confusion 
of  current  classifications.  The  term  simple  infection  as  distinguished 
from  septic,  for  example,  has  no  strict  pathological  meaning.  So-called 
simple  infection,  at  least  in  a  mild  degree,  is  septic.  We  know  that 
an  infection  seemingly  very  mild  may  take  on  readily  a  decidedly 
\nrulent  character.  What  is  there  in  such  conditions  to  designate  on 
the  one  hand  as  simple,  on  the  other  as  septic?  In  the  present  state 
of  our  knowledge  we  must  use  for  descriptive  purposes  an  adaptable 
and  therefore  flexible,  nomenclature.  In  such  nomenclature  words 
like  simple  and  septic  can  have  only  a  loose  clinical  significance.  They 
cannot  be  utilized  as  the  outcome  of  scientific  classification.  We  may 
simplify  the  subject  by  throwing  out  such  a  word  as  simple. 

A  distinction  between  acute  and  chronic  inflammation,  since  these 
conditions  enter  extensively  into  the  pathology  of  the  diseases  of 
women,  is  most  important.  ]\Iany  deny  altogether  the  existence,  for 
example,  of  chronic  inflammation  of  the  endometrium.  Some  attribute 
the  condition  which  usually  is  classed  under  that  name  to  congestion; 

'  Luther.     Sammlung  klinische  Vortrage.  1893. 


174     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

others  call  it  a  subinfiammatory  state.  It  may  be  well  to  remark 
that  an  essential  factor  of  inflammation — round-cell  infiltration — is 
found  in  those  chronic  conditions,  and  that  they  may  therefore  be  classed 
properly  as  inflammatory;  the  migration  of  white  corpuscles,  however, 
occurs  more  slow^ly,  and  may  in  some  cases  be  very  slight.  In  this 
respect  the  difference  between  acute  and  chronic  inflammation  is  one 
of  degree.  We  shall  avoid  the  question  whether  certain  conditions 
should  be  called  congestive,  inflammatory,  or  subinfiammatory.  The 
discussion  of  this  question  is  tiresome  and  unprofitable — a  contest 
largely  of  words.  The  following  outline  of  some  of  the  phenomena 
of  inflammation  will  help  make  clear  the  distinction  between  acute 
inflammation  and  the  conditions  which  usually  are  grouped  under  the 
name  chronic  inflammation. 

The  inflammatory  reaction  which  living  tissue  exhibits  to  morbid 
irritation  is  first  defensive,  and  then  constructive  or  reparative.  The 
defensive  process  is  an  effort  to  circumscribe  the  disease  by  throwing 
around  it  a  limited  wall  of  exudate;  the  morbid  force  thus  confined 
and  concentrated  within  narrow  limits  is  within  these  limits  more  or 
less  intense  and  destructive.  It  may  result  in  the  sacrifice  of  a  part 
for  the  safety  of  the  whole.  The  force  of  the  disease  is  spent  in  the 
destructive  process,  and  may  be  active  only  or  chiefly  within  the  limit- 
ing wall.  Finally,  normal  conditions  of  nutrition  are  re-established, 
the  constructive  or  reparative  process  becomes  active,  and  the  limiting 
wall  is  absorbed.  If  the  constructive  process  continues  until  repair  is 
complete  and  then  ceases,  the  part  will  resume  its  normal  functions— 
the  inflammation  will  be  at  an  end. 

Acute  Inflammation. — If  the  infection  is  of  such  virulence  or  other- 
wise of  such  character  as  to  call  forth  the  defensive  processes  just 
described,  and  to  produce  blood-stasis  with  more  or  less  severe  swelling, 
pain,  heat,  and  redness,  and  finally  to  produce  local  destruction,  the 
inflammation  is  acute.  The  disease  may  terminate  with  resolution  or 
go  on  to  suppuration. 

Chronic  Inflammation. — If  the  irritation  is  of  minor  intensity,  or 
in  any  other  way  of  such  character  as  to  fall  short  of  provoking  much 
defensive  action,  there  will  be  little  or  no  limiting  wall,  and  consequently 
no  intense  destructive  process  concentrated  within  a  circumscribed 
space;  heat,  swelling,  pain,  and  redness,  if  present,  will  be  more  diffuse 
and  less  pronounced.  Chronic  inflammation  occurs  under  these  con- 
ditions— a  minimum  of  defence  and  an  excess  of  construction. 

Chronic  inflammation  may  follow  acute  infection,  or  may  have  been 
subacute  or  chronic  in  the  beginning.  The  excessive  constructive  action 
which  belongs  to  it  explains  the  hyperplastic  and  hypertrophic  results 
of  so-called  chronic  metritis.  It  also  explains  certain  morbid  nutri- 
tive changes  in  the  blood-  and  lymph-vessels  of  the  pelvis  and  in  the 
cellular  tissue  of  the  pelvis.  Sclerotic  changes  in  other  organs,  such  as 
arteriosclerosis  and  interstitial  nephritis,  offer  a  close  analogy. 

It  is  unprofitable  to  speculate  on  the  question  whether  the  condi- 
tions just  described  under  the  name  chronic  inflammation  may  better 


iM'KcTjoxs  or  Till'.  h-i-:i'h'<)i)icri\r:  oay;.lv.s'  175 

he  classiHtMl  as  coiiiffstix't'  or  as  suhiiillamiiiatory  states.  They  are 
r('C(),uiii'/al)K'  under  either  of  tliese  names.  Tliey  oeeur  more  freciuently 
in  neiiropathie  women,  and  espeeially  in  eases  of  the  various  (hatheses 
— ana?mia,  Hthiemia,  ^out.  ehohemia.  They  are  usually  less  dangerous 
to  life  and  often  more  destructive  to  health  than  the  acute  inflam- 
mations. They  constitute  a  larije  proportion  of  the  diseases  of  women 
and  include  some  of  the  most  distressing  ailments.  They  are  persistent 
and  hard,  often  impos.sible  to  cure.  In  sueh  eases  it  is  frequently 
difficult  to  draw  the  lines  between  congestions  which  are  inflammatory 
and  congestions  which  are  non-infiammator\-.  One  of  the  most  common 
forms  of  so-called  uterine  catarrh  is  that  which  occurs  in  women  of 
deficient  eliminative  power — that  is,  the  bowels,  kidneys,  and  other 
eliminative  organs  fail  sufficiently  to  throw  ofi'  the  waste-products. 
Under  these  conditions  the  mucous  glands  of  the  uterus,  for  examj)le, 
whose  function  is  not  excretory,  may  undertake  \icari()usly  to  make 
good  the  deficiency.  An  unspeakable  amount  of  iiiiadireded  and  in- 
jurious local  treatment  is  constantly  being  applied  to  the  endometrium 
in  such  cases. 

The  significance  of  pelvic  infection  varies  according  to  the  resist- 
ance of  the  patient,  to  the  location  and  nature  of  the  structures  in- 
volved, and  to  the  virulence  of  the  cause  which  produced  it.  Decided 
predisposing  causes  make  the  woman  less  able  to  resist  morbid  irrita- 
tion; and  infection  once  established  is  more  likely  to  be  se^'e^e  and 
progressive.  If  infection  is  confined  to  superficial  areas,  its  gravity 
is  relatively  much  less  than  when  deeper  structures  are  diseased.  Endo- 
metritis, for  example,  is  less  serious  than  an  inflammation  involving 
the  uterine  wall  or  the  parametric  lymphatics  and  veins.  ^Moreover, 
the  same  kind  of  infection  may  be  more  serious  in  some  places  than  in 
others.  This  may  be  illustrated  by  the  case  of  a  man  who  picked  his 
teeth  with  a  vaccine  point  and  experienced  a  most  distressing  result. 
Some  bacteria  are  harmless  and  some  only  mildly  virulent.  The  gono- 
coccus  is  more  frequent,  and  therefore  more  disabling  than  the  staphy- 
lococcus.   The  streptococcus  pyogenes  is  more  dangerous  than  either. 

From  the  foregoing  it  is  easy  to  explain  why  an  infection,  even 
in  the  deeper  structures,  may,  if  not  from  very  destructive  bacteiia, 
present  in  the  more  acute  stages  most  of  the  subjective  and  some  of 
the  objective  appearances  of  a  fatal  disease,  and  yet  after  a  few 
days  terminate  in  complete  health.  The  reason  is  also  obvious  why  a 
superficial  vulvar  infection,  apparently  innocent,  may  be  the  result  of 
gonococcus  or  streptococcus  invasion,  and  by  continuity  of  surface,  or 
by  way  of  the  vessels,  may  extend  and  finally  destroy  life  or  render 
it  miserable  and  useless.  Some  organisms  may  excite  little  or  no 
defence — /.  e.,  may  not  attract  leucocytes — and  may  therefore  sweep 
through  the  system  with  rapidly  destructive  and  fatal  force.  The  germ 
of  tetanus,  for  example,  gives  rise  to  infection  but  does  not  excite  defen- 
sive inflammation. 


176     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 


Diagnosis,   Prognosis,  and  Treatment  of  Infection  and 
Inflammation 

The  symptoms  are  often  utterly  disproportionate  to  the  gravity 
of  the  lesions.  An  infection  of  little  danger  may  cause  the  greatest 
suffering;  another,  which  directly  threatens  life,  may  be  almost  pain- 
less. Objective  examination,  therefore,  especially  in  acute  cases,  is 
important.  The  subjective  symptoms  may  be  misleading.  The  prog- 
nosis depends  upon  the  region  infected,  the  general  and  local  resist- 
ance of  the  patient,  and  the  extent  and  nature  of  the  infection. 

The  treatment  requires  the  individualization  of  each  case,  and  the 
reader  must  therefore  be  referred  to  the  special  subjects. 


riT  AFTER    XT 

vrLViTis.  vrL\()\A(;i\iTis,  vaginitis 

Infkctions  ot"  till'  \iil\a  and  \ajiina  may  occur  separately,  hut 
tlu\\  conunoniy  appear  in  C()iiil)iue(l  form:  to  avoid  repetition  and  to 
simplify  tlie  subject,  therefore  viihutis,  I'uginitl.s,  and  vulvuvayinitLf  so  far 
as  practicable  will  \)v  descril)ed  tojjether. 

The  imj)ortance  of  \uhitis  and  vulvovaij;initis  commonly  is  under- 
estimated. Inflammation  seemingly  trivial  may  start  in  the  vuKa 
and  rapidly  extend  to  all  the  reproductive  and  urinary  organs,  and 
may,  therefore,  give  rise  to  metritis,  salpingitis,  ovaritis,  peritonitis, 
urethritis,  cystitis,  pyelitis,  and  nephritis. 

The  external  genitals  are  the  labia  majora  and  minora;  the  clitoris, 
with  its  prepuce;  the  vestibule,  including  the  meatus  urinarius;  the 
fossa  na^"iclda^is  and  the  hymen.  The  hymen  separates  the  external 
genitals  from  the  vagina.  The  covering  of  the  external  genitals  is 
cutaneous,  although  it  partakes  somewhat  of  the  nature  of  mucous 
membrane. 

The  general  consitleration  of  vulvar  and  vaginal  inflammations 
includes  certain  factors  in  etiology,  pathology,  and  diagnosis  which 
are  more  or  less  common  to  all  varieties.  To  avoid  repetition  and  to 
give  a  general  impression  of  the  whole  subject,  these  factors  may  be 
studied  before  taking  up  the  special  form. 

General   Consideration   of  Etiology 

Predisposing  Causes  or  Favoring  Conditions  have  been  outlined 
in  Chapter  X.  Among  the  conditions  which  specially  predispose  to 
vulvovaginal  inflammation  are  the  following: 

Filth.  ^'aginal  fistulse. 

Obesity.  Excessive  coitus. 

Defective  nutrition.  ]\Iasturbation. 

Foreign  bodies,  such  Diabetic  and  other 
as  pessaries,  etc.  irritating  urine. 

Filth  outranks  every  other  cause,  with  the  possible  exception  of  the 
gonococcus.  In  fat  women  of  sluggish  capillary  circulation  the  vulva 
is  supersensitive  to  undue  irritation.  The  excessive  oily  secretions 
undergo  decomposition  into  fatty  acids,  which  cause  intense,  intract- 
able erythema  of  the  vulva,  and  often  of  the  thighs  and  nates,  a  con- 
dition aggravated  by  filth — /.  r.,  by  accumulated  and  decomposed 
secretions  especially  in  warm  weather,  when  perspiration  is  free.  Mas- 
12  '  (177) 


178      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

tiirbation  may  be  a  cause  or  a  result  of  the  disease.     Badly  nourished, 
neuropathic  and  diathetic  women  are  predisposed  to  chronic  infection. 

Children  are  particularly  subject  to  vulvovaginal  inflammations  as  a 
sequel  of  such  acute  infectious  diseases  as  diphtheria,  scarlatina,  noma, 
smallpox,  and  enteric  fever,  and  if  of  defective  nutrition,  moreover,  are 
especially  prone  to  suppurative  vulvitis. 

Among  the  Media  of  Infection  are:  Pathological  discharges  from 
the  uterus,  Fallopian  tubes,  and  vagina.  Pelvic  abscesses  discharging 
into  the  vagina,  urine,  and  feces,  carcinomatous  discharges,  pediculi 
pubis,  and  other  parasites. 

The  disease  may,  especially  in  cases  of  severe  pruritus,  come  by 
extension  from  the  anus;  very  often  the  morbid  irritation  is  furnished 
by  organisms  from  the  diseased  bladder,  ureters,  or  kidneys.  Infec- 
tion may  originate  in  the  vulva  or  from  the  surrounding  cutaneous 
surface.  It  may  result  from  direct  infection  or  from  an  irritating 
discharge  from  some  higher  zone  in  the  pelvis. 

Exciting  Causes. — Chief  among  the  organisms  which  are  known  to 
produce  vulvovaginal  infection  are  the  following: 

Gonococcus.  Bacillus  of  tuberculosis. 

Micrococcus  of  erysipelas.  Bacillus  of  chancroid. 

Bacillus  of  diphtheria.  Spirochete  of  syphilis. 

Mycotic  organisms. 

Other  forms  of  vulvovaginal  infection  are  caused  often  by  other 
micro-organisms,  chief  among  which  are  staphylococcus  aureus,  albus, 
and  citreus.  A  rare  vaginal  disease  has  been  described  under  the  name  of 
emphysematous  vaginitis,  doubtless  caused  by  one  of  the  gas-producing 
organisms,  bacillus  aerogenes  capsulatus  or  bacillus  coli  aerogenes. 

General  Consideration  of  Pathology 

Vulvar  and  vaginal  inflammation,  whatever  the  exciting  cause,  may 
attack  special  structures,  such  as  the  skin,  mucous  membrane,  cellular 
tissue,  glands,  and  follicles;  thus  we  may  distinguish: 

Superficial  vulvovaginitis.  Paravaginitis. 

Senile  vulvovaginitis.  Follicular  vulvitis. 

Glandular  vulvitis.  Furuncular  vulvitis. 

The  classifications  above  outlined  cannot  from  the  clinical  stand- 
point always  be  followed.  An  effort,  however,  to  differentiate  between 
the  various  forms  should,  for  both  clinical  and  scientific  reasons,  be 
attempted. 

Catarrhal,  suppurative,  hemorrhagic,  and  ulcerative  processes  are 
rather  phases  than  varieties  of  inflammation.  The  process  is  catarrhal 
when  the  product  is  a  pathological  increase  of  the  normal  secretion, 
suppurative  when  it  contains  pus,  hemorrhagic  when  it  contains  an 
appreciable  amount  of  blood — i.  e.,  when  the  destructive  process  has 
opened  the  walls  of  the  vessels — and  ulcerative  when  there  is  localized 
necrosis.  The  catarrhal  often  precedes  the  suppurative  infection  by  a 
distinct  period. 


VILVITIS,    \  riAOVAGIMTlS,    \'A(JINiriS 


17'J 


Leucarrhwn  is  the  iiaiiie  v;ij;uely  and  i)(»|)ularly  ^i\eii  to  any  disc-harge 
ho\\\  the  <;enitals.  Strictly  the  term  sliould  be  reserved  for  a  whitish 
discliarge  of  increased  mucus. 

The  skin  or  nuicous  membrane  in  chronic  cases  usually  becomes 
tliick  and  (rdcniatous.  The  pyof>;enic  bacteria  do  not  produce  sup- 
puration until  the  structures  are  impaired  in  a  dc<i;ree.  A  circnm- 
scribed  supi)uratinfi;  surface  may  be  surrounded  by  an  area  of  catarrhal 
inflaunnation.  The  necrotic  tendency  may  not  go  beyond  erosion;  it 
merely  may  impair  without  destroying  the  skin  or  mucosa.  Numerous 
minute  i)oints  of  superficial  su])i)uration  in  a  limited  area  may  run 
together  and  form  an  ulcer.  In  this  way  many  areas  of  ulceration 
may  be  formed.  If  ulcerative  changes  involve  the  small  blood-vessels, 
the  secretions  will  be  streaked  with  blood.  Severe  cases  may  present 
hemorrhagic  areas,  great  swelling,  and  even  gangrene. 


Figure  79 


Granular  vaginitis.     Apt  to  be  of  gonorrhoea!  origin.     Observe  the  purulent  secretion  on  the 

posterior  vaginal  wall. 

In  so-called  granular  vulvovaginitis  the  granulation  is  due  to  swelling 
and  hypertrophy  of  the  vulvovaginal  papilla^;  it  is  found  chiefly  in 
the  vagina,  and  is  commonest  during  pregnancy,  though  not  con- 
fined to  that  period.  It  is  characterized  by  small,  round,  protuberant 
granulations  scattered  thickly  over  the  affected  surface. 

Sufficient  plastic  material  may  be  thrown  out  to  cause  adhesions, 
more  or  less  firm  between  the  nymphfe  or  the  labia  majora,  or  between 


180      INFECTIONS,   INFLAMMATIONS,    AND   ALLIED   DISORDERS 

the  vaginal  walls,  or  between  the  vagina  and  the  cervix  uteri.  Partial 
or  complete  closure  of  the  vulva  by  adhesions  is  not  uncommon  in 
children.  Such  adhesions  usually  yield  to  slight  force.  They  resemble 
the  adhesions  sometimes  found  between  the  prepuce  and  the  glans 
penis  of  the  male  child;  they  also  may  occur  between  the  clitoris  and 
its  prepuce,  and  may  give  rise  to  serious  nervous  disturbances.  vStrong 
adhesions  are  less  likely  to  occur  in  married  women  than  in  virgins 
and  aged  women  w^hose  organs  are  at  rest.  Extension  of  vulvar 
inflammation  to  the  vagina  is  common,  though  not  so  common  as  it 
would  be  were  it  not  for  the  following  anatomical  and  physiological  con- 
ditions of  the  vagina:  it  is  smooth  and,  being  covered  with  pavement 
epithelium,  closely  resembles  skin;  is  almost  if  not  quite  destitute  of 
glands,  and  is  therefore  not  subject  to  intense  catarrhal  affections. 

Doderlein  has  distinguished  microscopically  two  secretions  of  the 
vagina:  one  the  normal  secretion,  a  whitish,  milky,  strongly  acid  dis- 
charge without  mucous  admixture;  the  other  a  pathological  secretion, 
yellowish,  faintly  acid,  often  neutral  or  alkaline,  sometimes  foamy  and 
mixed  with  mucus.  In  the  normal  vaginal  secretion  a  non-pathogenic 
vaginal  bacillus  v/as  constantly  present.  Doderlein's  experiments 
with  cultures  showed  that  this  bacillus  gives  to  the  normal  secre- 
tion its  acid  reaction,  which  is  due  to  lactic  acid.  These  normal 
vaginal  bacilli  were  found  to  be  unfavorable  to  the  growth  of  staphy- 
lococcus pyogenes  aureus.  In  fact,  the  vast  majority  of  pathogenic 
bacteria  do  not  thrive  in  an  acid  medium.  In  the  pathological  secre- 
tion Doderlein  found  the  pathogenic  bacteria  to  be  increased  and  the 
normal  vaginal  microbes  to  be  decreased.  The  abnormal  secretion 
usually  originates  in  the  cervix  uteri,  is  toxic  to  animals,  and  by  its 
hostility  to  the  normal  vaginal  microbes  decreases  or  neutralizes  the 
acidity  of  the  vaginal  secretion,  thereby  affording  a  favorable  culture- 
ground  in  the  vagina  for  pathogenic  bacteria. 

When  vaginitis  occurs  the  desquamated  cells  of  vaginal  epithelium 
give  rise  to  a  thick,  pasty  smegma-like  secretion  not  unlike  vernix 
caseosa.  When  the  epithelium  is  shed  and  the  deeper  structure  ex- 
posed, creamy  abundant  and  malodorous  pus  may  be  thrown  off  from 
the  exposed  surfaces. 

Vulvovaginitis,  if  superficial,  strongly  tends  to  recovery.  It  becomes 
obstinate  when  the  vulvar  glands  already  described  are  involved,  and 
may  be  intractable  when  the  infection  reaches  the  muciparous  glands 
of  the  uterus.  Reference  is  made  to  the  remarks  in  the  preceding 
chapter  on  the  relative  capacities  of  the  vulva,  vagina,  and  cervix  to 
receive,  retain,  and  distribute  infection. 

General  Considerations  of  Symptoms,   Diagnosis, 
and  Prognosis 

Symptoms. —  The  symptom-group  in  acute  vulvovaginal  inflammation 
comprises  irritation,  pain,  redness,  swelling,  heat,  and  increased  secre- 
tion.    The  systemic  symptoms  of  inflammation  are  absent  or  slight, 


\IL\ITIS,    \ll.\()\A(;/.\/T/S,    \A(;i\ITIS  ]S1 

except  ill  ("isi>s  of  cxtciisix  (•  |)lil(\u,iii()ii  or  suppiirat  ion.  Tlic  pain  and 
s\v('lliii<;-  are  often  so  intense  that  the  patient  ninst  he  down  with  the 
thi»;lis  apart.  The  hd)ia  minora  sometimes  swell  to  twice  the  size  of 
the  fiiifier,  anil  consequently  may  close  the  vulva;  they  have  a  bright, 
glistening,-  appearance  not  unlike  the  inflamed  swollen  prepuce  of  the 
male.  The  i)ain  is  throbbing-  and  extreme  in  proportion  to  the  swelling. 
The  inllamed  surfaces,  which  may  include  both  \ulva  and  \agiiia, 
are  at  first  dry,  but  soon  become  moist  in  cousecjuence  of  an  effort  of 
the  glands  to  relieve  the  congestion  by  increased  secretion.  The  secre- 
tion, usually  profuse,  is  the  chief  evidence  of  the  disease.  In  children 
the  disease,  unless  due  to  gonorrha^al  infection,  is  confined  usually 
to  the  vulva.  Carcinomatous  ichor  causes  irritation  rather  than  jjain. 
Frequent  difficult  and  painful  urination  are  common,  especially  when 
the  infection  has  extended  to  the  urethra  and  bladder. 

Chronic  J^iilritis  and  ]^agi)iitls  may  occur  separately  or  together. 
Clinically,  chronic  vulvitis  and  vaginitis  are  observed  more  commonly 
than  acute;  they  may  follow  the  acute,  or  may  have  been  chronic  or 
subacute  in  the  beginning;  they  are  recognized  by  their  persistence, 
by  their  tendency  to  recur  when  apparently  cured — see  Follicular  and 
Glandular  A'ulvitis — and  sometimes  by  the  presence  of  erosion  of  the 
vulvar,  vaginal,  or  vulvovaginal  surfaces.  They  are  characterized  by  a 
scanty,  thin,  yellow  discharge,  usually  more  or  less  purulent;  by  great 
local  irritation;  by  variable  redness;  by  slight  swelling,  and  sometimes 
by  excessive  granulation.  The  surfaces,  especially  the  vulvar  surfaces, 
finally  become  hard,  oedematous,  leathery,  parchment-like,  and  painful. 
A  frequent  symptom  of  chronic  vulvar  inflammation  is  an  intolerable 
pruritus,  characterized  by  intractable  itching  and  burning.  See  Pruritus 
Vulvte. 

Diagnosis. — The  purpose  of  a  diagnosis  is  not  so  much  to  give  a  name 
to  the  disease  as  to  furnish  a  basis  of  rational  treatment;  a  diagnosis 
should  include,  therefore,  the  source,  variety,  and  complications  of  the 
disease.  It  would  be  absurd  to  confine  the  treatment  to  the  area  of 
inflammation  if,  for  example,  the  disease  were  secondary  to  metritis, 
carcinoma,  cystitis,  or  vaginal  fistula.  Attention  to  such  complica- 
tions as  fissure  in  ano,  hemorrhoids,  rigid  sphincter,  thread-worms,  and 
endometritis  often  gives  relief.  The  diagnosis  should  have  special 
reference  to  the  possible  extension  of  the  disease  into  the  ducts  of 
the  vulvar  glands  and  urinary  organs.  The  discharge  from  a  pelvic 
abscess  has  been  mistaken  for  the  secretions  of  vulvovaginitis. 

Although  tentative  recognition  of  bacterial  infection  made  from 
the  character  and  location  of  the  inflammation  and  secretions,  definite 
diagnosis  is  possible  only  through  microscopical  or  cultural  examination. 

Prognosis. — Vulvovaginitis,  if  superficial,  strongly  tends  to  recovery. 
It  becomes  obstinate  when  the  vulvar  glands  already  described  are 
involved,  and  may  be  intractable  when  the  infection  reaches  the  muco- 
parous  glands  of  the  uterus.  Reference  is  made  to  the  remarks  in  the 
preceding  chapter  on  the  relative  capacities  of  the  vulva,  vagina,  and 
cervix  to  receive,  retain,  and  distribute  infection. 


182      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

General   Considerations   of   Treatment 

A  lesson  to  be  learned  from  the  above  observations  is  the  importance 
of  stamping  out  vulvar  inflammation,  and  thereby  preventing  its  inva- 
sion of  the  higher  zones  in  the  pelvis.  The  experiments  of  Doderlein 
would  suggest  vaginal  douches  of  a  1  per  cent,  aqueous  solution  of 
lactic  acid.  This  would  clearly  not  apply  to  infection  from  bacteria 
which  grow  in  acid  media. 

Prophylaxis. — The  vulva  is  normally  moist  from  its  own  secretions. 
Dust  and  dirt,  which  may  contain  irritants  capable  of  exciting  vulvitis, 
easily  reach  the  vulva  and  find  lodgement  there.  As  a  prophylaxis 
against  this  source  of  vulvitis,  and  as  a  better  protection  against  sudden 
changes  of  temperature,  the  closed  drawers  should  take  the  place  of 
the  commonly  worn  open  drawers.  The  dail}'  shower-bath  applied 
to  the  external  genitals  is  an  excellent  prophylaxis.  Strong  soap  is 
irritating,  and  therefore  injurious. 

The  Treatment  of  Acute  Vulvovaginil;is  is  chiefly  local,  and  includes 
two  essentials — cleanliness  and  palliation.  Mild  alkaline  solutions, 
such  as  sodium  bicarbonate,  when  applied  to  the  vulva,  may  combine 
with  the  oily  secretion  to  form  a  soap  which,  upon  being  washed  off 
with  warm  water,  leaves  the  surface  clean.  Washing  should  be  re- 
peated frequently  as  a  preparation  for  other  applications,  such  as  a 
lotion  of  equal  parts  of  dilute  solution  of  acetate  of  lead  and  fluid 
aqueous  extract  of  opium;  the  4  per  cent,  aqueous  solution  of  antipy- 
rine;  the  4  per  cent,  solution  of  cocaine;  the  4  per  cent,  ointment  of 
morphine  sulphate.  The  warm  sitz-bath  or  the  ice-bag  applied  to  the 
vulva  is  indicated  in  cases  of  extreme  irritation  and  burning.  Absolute 
rest  in  bed  is  important.  A  rectal  suppository  containing  extract  of 
opium,  two  grains,  and  extract  of  belladonna,  one-fourth  grain,  may 
give  relief  and  secure  much-needed  sleep.  Avoid  ointments  containing 
animal  fat.  Vaseline,  clear  or  stiffened  with  wax,  is  a  good  excipient. 
A  combination  of  orthoform  15  per  cent.,  argyrol  15  per  cent.,  and  Dase- 
line  70  per  cent.,  may  be  applied  daily  with  most  satisfactory  results. 
In  the  use  of  orthoform,  special  care  should  he  exercised  to  discontinue 
the  drug  in  case  of  bismuth  -poisoning.  This  ointment  may  be  con- 
veniently put  up  in  collapsible  tubes,  from  which  it  may  be  squeezed 
into  the  vagina  through  a  speculum  and  held  there  by  a  rather  loosely 
packed  strip  of  gauze.  A  tolerably  hot  douche  should  be  given  before 
the  ointment  is  applied. 

Buboes  and  other  abscesses  if  they  occur  should  be  opened.  Great 
care  is  needed  to  avoid  carrying  the  infection  from  the  vulva  to  the 
vagina  or  uterus  by  the  syringe-tube  or  examining-finger. 

The  general  treatment  consists  of  saline  purges,  and  soporifics  and 
anodynes  as  indicated  by  nervous  irritation  and  pain. 

The  Treatment  of  Chronic  Vulvovaginitis  includes,  in  addition  to  such 
of  the  above  mean^  as  may  he  indicated,  astringents  and,  in  obstinate 
cases,  caustics.  The  surfaces  should  be  dressed  with  gauze  compresses 
saturated  with  a  1 :  3000  aqueous  solution  of  the  bichloride  or  mercury. 


Vri.VIT/S,    VriA-OVAdlMTlS,    ]A(!l\/TIS  1S3 

It"  the  disease  has  heeii  causecl  l)y  pediciili  pubis  or  ()th<T  parasites, 
iiKTcurial  ointment,  in  addition  to  the  al)o\e  sohitions,  should  he  used 
to  destroy  them.  One  of  the  most  efl'eetive  treatments  is  the  daily 
paekiufj  of  the  vaj^ina  with  ;jauze  saturated  with  an  acpieous  sohition 
of  ar^yrol,  15  per  cent. 

The  daily  hot-water  vaginal  douche  may  be  supplemented  l)y  fre- 
(pient  compresses  of  [Merck's  aqueous  solution  of  aluminum  acetate  to 
the  vuha.  This  application  w  pnrticularly  I'ffcclice  an  an  antiseptic 
and  local  anesthetic  in  case  of  intolerable  vulvar  irritation.  Extensi\'e 
erosion  of  the  skin  about  the  vulva  often  is  cured  promptly  by  the  free 
use  of  benzoated  oxide  of  zinc  ointment.  Eroded  surfaces,  having 
been  dried,  may  be  dusted  daily  with  calomel  or  with  the  subgallate  of 
bismuth. 

In  neuropathic  cases  of  severe  pruritus  almost  miraculous  relief  some- 
times follows  the  free  withdrawal  of  bhxxl  from  the  uterus,  either  by 
scarification  or  by  leeches. ' 

Granular  vulvitis  should  be  treated  by  painting  the  granulated  part 
with  a  1 :  20  solution  of  nitrate  of  silver  and  daily  packing  the  vagina 
with  gauze.  The  application  is  made  best  with  a  compress  secured  by 
a  bandage.  The  treatment  of  vulvar  and  vaginal  infection  may  fail 
until  a  causal  or  complicating  endometritis  has  been  cured. 


SPECIAL  FORMS  OF  BACTERIAL   VULVOVAGINAL  INFLAMMATION 

Gonorrhoea!  Vulvovaginitis 

Gonorrhoea,  one  of  the  most  active  and  most  destructi\'e  infections 
in  the  reproductive  organs,  is  always  the  result  of  gonococcus  infection. 
The  disease  is  characterized  by  a  strong  tendency  to  penetrate  and 
spread,  and  is  prone  to  attack  the  follicles  and  glandular  structures 
of  the  vulva,  especially  the  vulvovaginal  glands  and  Skene's  glands. 
See  Glandular  Vuhatis.  Diffuse  and  deep  cellular  inflammation  and 
abscess  of  the  vulva  may  also  result  from  gonococcus  infection.  See 
remarks  on  the  Gonococcus  and  Recurrent  Gonorrhoea  and  Urethritis 
in  Chapter  XXI. 

The  infection  has  the  strongest  tendency  to  spread  throughout  the 
genito-urinary  tract,  although  the  constant  downward  current  of  urine 
may  protect  in  a  measure  the  more  distant  urinary  organs.  If  the 
disease  originates  in  the  vulva  it  usually  extends  to  the  vagina,  and 
vice  versa.  The  urethra  ivhich  seldom  escapes  demands  particular  atten- 
tion. The  inguinal  glands  concurrently  may  be  infected  through  the 
lymphatics,  and  are  then  especially  prone  to  suppuration. 

Children  are  much  more  subject  to  this  infection  than  is  popularly 
supposed.  It  may  come  from  infected  bed-linen,  from  bathing  with  in- 
fected cloths  or  sponges,  or  from  the  unclean  hands  of  infected  nurses. 
In  children  the  disease  perhaps  is  less  liable  than  in  adults  to  extend 
to  the  vagina,  because  the  vagina  is  protected  in  a  measure  by  the 


184      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

hymen.     It  may,  however,  easily  be  carried  upward  on  the  douche- 
point. 

Such  infection  may  run  hke  wildfire  through  a  family,  or  the  chil- 
dren's ward  of  a  hospital.  The  prepuce  and  glans  penis  of  male  children 
are  by  no  means  immune  against  the  careless  hand  of  the  nurse. 

Diagnosis.— Sudden  onset  of  great  pain,  burning  and  smarting,  espe- 
cially on  urination,  and  copious  mucopurulent  discharge,  are  the  dis- 
tinctive signs,  which  if  they  follow  one  to  seven  days  after  a  suspicious 
exposure,  and  are  associated  with  variable  chill,  accelerated  pulse,  and 
some  degree  of  fever  are  almost  pathognomonic  of  acute  gonorrhoeal 
infection.  The  pain  at  first  localized,  soon  radiates  to  the  rectum, 
vagina,  perineum,  and  bladder. 

Positive  diagnosis  depends  on  the  microscopic  findings.  "The  go7ior- 
rhoea  complement  fixation  test  will  detect  the  gonococcus  anywhere 
in  the  body,  in  any  variety  of  the  disease,  acute  or  chronic.  During  or 
after  the  fourth  week  of  the  disease,  it  is  of  importance  to  the  gynecol- 
ogist: first,  to  prove  that  a  given  leucorrhea  is  or  is  not  gonorrhoea; 
second,  to  prove  that  a  given  pus-tube  is  or  is  not  gonorrhoea;  third, 
to  prove  that  a  given  pelvic  cellulitis  or  peritonitis  is  or  is  not  gonor- 
rhoea; fourth,  to  prove  that  a  given  endometritis  or  cervicitis  is  or 
is  not  gonorrhoea;  fifth,  to  aid  in  differentiating  an  acute  appendicitis 
from  an  acute  salpingitis;  sixth,  to  explain  the  occurrence  of  puer- 
peral fever  in  cases  that  have  been  handled  in  an  absolutely  clean 
way,  when  the  origin  of  the  disease  is  in  doubt;  seventh,  before  labor 
in  a  suspicious  case  to  take  precautions  so  that  extraordinary  care  can 
be  given  as  to  gonorrhoeal  infection  of  the  baby's  eyes."^ 

Prognosis. — The  gonococcus  of  Xeisser,  as  observed  above,  is  one  of 
the  most  frequent,  destructive,  and  insidious  factors  in  genito-urinary 
infection;  its  chief  power  for  harm  lies  in  the  lasting  vitality  of  the 
germ  long  after  apparent  cure.  The  gonococcus  may  remain  inactive 
in  the  mucous  crypts,  liable  at  any  time,  even  while  quiescent  in  the 
individual,  to  be  communicated  to  another.  Hence,  many  an  innocent 
and  previously  healthy  woman,  shortly  after  marriage  to  a  man  who 
supposed  himself  to  have  been  cured  of  gonorrhoea  years  before,  may  by 
contact  wath  the  attenuated  virus  get  a  destructive  gonorrhoeal  infec- 
tion of  the  genito-urinary  organs.  Some  most  important  observations 
upon  this  subject  have  been  made  by  Wertheim.  A  direct  experiment 
with  pure  culture  from  a  gleety  discharge  of  two  years'  standing  gave 
the  following  interesting  results:  (1)  attempted  reinfection  of  the 
original  urethra  with  this  culture  was  always  a  failure ;  (2)  the  culture 
when  transplanted  to  a  coccus-free  urethra  produced  typical  acute 
gonorrhoea;  (3)  infection  from  this  back  again  to  the  original  urethra 
gave  a  fresh  gonorrhoea,  w^hich  after  a  typical  acute  course  of  five  or 
six  weeks  again  subsided  into  a  chronic  gleet.  Thus  by  passing  the 
gonococci  through  another  individual — that* is,  through  new  culture 

1  Quoted  from  a  paper  by  Victor  B.  Lespinasse  and  Maurice  Wolff.  Ulinois  Medical  Journal, 
January,  1913. 


VrLVITlS,    \(  LV()\A(;j.\IT/S,    l'.U,7.\777.s'  iSo 

j^roiiiul— tlit'N  l)t'c;iiiic  auMiii  xinilciit  to  the  urethra  wliicii  was  imiiiiiiic 
to  tlu'in  hrt'oro. 

This  <.'Xj)lains  the  tact  thai  an  ai)|)arriitlv  healthy  suhjeet  of  chronic 
gonorrluva  ina\  infect  his  hitherti)  uninfected  wife  and  become  again 
infected  from  lier — /.  c,  the  ijonococci  hy  passin<!:  tliron<;ii  tlie  new  cul- 
ture of  the  wife  a«;ain  may  he  \irulent  for  the  husband.  In  due  time 
each  becomes  tolerant  of  the  <!;erm;  which,  however,  may  develop  an 
acute  infection  in  another  person.  The  common  notion  that  <ionor- 
rhcra  in  women  may  be  chronic  from  the  beginning  is  weakened  in  the 
exi^eriments  of  Wertheim.  We  can  now  iniderstand  why  the  gonococcus, 
even  after  years  of  ai)j)arent  cure,  may  re<j;ain  its  full  \irulence. 

The  greatest  danger  of  gonorrhoea,  extension  to  the  Fallo})ian  tubes, 
will  be  considered  in  the  chapter  on  Salpingitis.  The  microbe  may 
be  found  in  the  uterus  and  tubes  long  after  it  has  disappeared  from  the 
vagina.  The  pavement  epithelium  of  the  vagina  and  the  acid  reaction 
of  the  secretion  normally  found  there  make  the  vagina  relati\"ely  immune. 
The  crypts  of  the  uterine  and  tubal  mucosa  furnish  a  ready  resting- 
I)lace  for  the  germ.  Even  here,  in  many  cases,  it  is  found  only  during 
the  exacerbations.  ^Menstruation  favors,  but  does  not  insure  its  revival. 
It  may  for  long  periods  remain  concealed  in  a  semiquiescent  state,  a 
destroyer  of  health,  a  menace  to  life.  The  frequency  of  chronic  gonor- 
rhoea— the  latent  gonorrhoea  of  Xoeggerath — as  set.  forth  in  Aarious 
hospital  statistics  ranges  from  25  to  80  per  cent.;  at  any  rate  the 
percentage  is  very  high. 

The  statistics  quoted  above  are  taken  from  clinics  largely  made  up 
of  prostittites  and  semi-prostitutes,  a  fact  which  necessarily  will  modify 
a  judicial  estimate  of  their  value.-  It  is,  moreover,  essential  to  appre- 
ciate two  other  facts:  first,  the  evidence  on  this  most  complicated  ques- 
tion, although  sufficient  to  lead  to  the  greatest  apprehension,  is  not  yet 
sufficient  to  establish  definite  and  undeniable  proof  on  the  extreme 
side  of  the  question;  second,  many  excellent  clinical  observers  in 
private  practice  are  disposed,  on  the  whole,  to  qualify  the  danger  and 
to  conclude  that  it  is  vastly  overestimated.  If  the  questions  involved 
were  matters  only  of  scientific  interest,  their  solution  could  properly 
wait  for  further  and  more  exact  observation;  but  the  "danger  and 
duty  of  the  hour"  are  concerned  'uith  moral,  not  scientific,  problems, 
and  the  moral  obligations  are  serious  enough  to  lead  the  writer  to 
present  the  subject  even  from  the  ex  parte  standpoint. 

Why  do  large  numbers  of  apparently  healthy  young  women  date 
their  pelvic  infection  from  the  marriage-week?  Is  it,  as  one  author 
declares,  the  "fatigue  and  excitement  of  the  wedding-journey?"  Why 
do  so  many  women  with  perfectly  de\'eloped  reproducti\e  organs  re- 
main .sterile  from  the  time  of  marriage  or  after  the  birth  of  a  single 
child  and  a  dangerous  "childbed  fever?"  The  causation  of  too  many 
such  cases  of  hopelessly  diseased  uteri,  tubes,  and  ovaries,  not  to 
mention  proctitis,  with  sometimes  rectal  stricture,  urethritis,  cystitis, 
pyelitis,  and  nephritis,  has  been  explained  by  the  word  idiopathic. 
The  histories,  if  written,  would  tell  often  of  an  apparently  cured  gonor- 


186      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

rhoea,  before  or  after  marriage,  in  the  husband.  If  the  most  destructive 
infection  may  follow  contact  with  a  subject  of  gonorrhoea  after  the 
discharge  has  ceased,  how  perilous  must  be  the  slight  gleety  discharge 
so  often  disregarded!  Young  men  sometimes  are  advised  to  marry 
in  order  to  improve  their  sexual  hygiene,  and  so  to  cure  an  intractable 
chronic  but  "innocent  gleet."  Such  advice  may  result  in  the  destruc- 
tion of  the  reproductive  organs  of  an  innocent  woman.  It  is  doubtless 
possible,  perhaps  not  unusual,  for  gonorrhoea  to  be  so  cured  that  the 
individual  cannot  transmit  the  disease.  Failure,  however,  to  cultivate 
the  gonococcus  from  the  urethral  secretions  does  not  prove  its  absence. 
So  long  as  it  can  be  cultivated  marriage  should  be  prohibited.  In 
every  suspected  case  marriage  should  be  deferred  at  least  until  repeated 
attempts  at  culture  have  failed.  A  gonorrhxal  record  does  not  necessarily 
settle,  hut  it  always  complicates  the  question  whether  the  indimdual  may 
safely  marry.  It  follows  from  the  above  that  there  is  no  absolute 
certainty  of  complete  cure  or  recovery  from  gonorrhoea. 

Treatment. — It  is  highly  important  to  stamp  out  gonorrhoeal  infec- 
tion w^hile  it  is  yet  in  the  vulva  and  vagina,  and  thereby'  to  keep  it  from 
going  to  the  higher  zones  of  the  genito-urinary  system. 

Prophylaxis. — Every  experienced  physician  is  keenly  alive  to  the 
rapidly  destructive  course  of  gonorrhoeal  conjunctivitis,  not  to  mention 
the  extension  of  the  disease  to  the  anus,  rectum,  and  urinary  tract. 
All  contaminated  linen  and  dressings,  therefore,  should  be  burned; 
clothing,  tow^els,  and  other  linen,  if  not  destroyed,  should  be  thoroughly 
disinfected,  so  that  they  cannot  by  any  possibility  carry  infection. 
The  use  of  the  bath-tub  in  common  is  prohibitory.  Husband  and  wife, 
nurses  and  children,  should  occupy  separate  apartments.  The  hand, 
a  frequent  carrier  of  infection,  should  be  kept,  not  only  esthetically, 
but  what  is  more  important,  surgically  clean.  The  utility  of  the  rubber 
glove  both  for  the  surgeon  and  for  nurse  cannot  be  too  strongly  empha- 
sized. All  instruments,  such  as  applicators,  douche-points,  syringe-tips, 
should  be  sterilized  by  boiling  water  immediately  before  and  after  using. 
In  this  relation  the  antiseptic  conscience  has  paramount  significance. 

General  treatment  includes  rest  in  bed,  light  diet,  copious  draughts 
of  not  less  than  two  quarts  of  water  a  day;  light  bland  diet,  and  the  use 
of  such  drugs  as  will  keep  the  bowels  free,  relieve  pain,  and  allay  the 
burning  and  scalding  of  urination,  as  follows:  saline  laxatives,  daily; 
belladonna  and  opium  suppositories  if  pain  is  urgent.  Hyoscine,  potas- 
sium acetate,  sweet  spirits  of  nitre,  balsam  copaiba,  eucalyptus,  sandal- 
wood-oil,  and  other  such  drugs  as  have  power  to  render  the  urine  less 
irritating,  or  the  urinary  tract  less  irritable  are  indicated  as  an  essential 
part  of  the  symptomatic  treatment. 

Local  treatment  in  the  acute  stage  consists  in  an  effort  to  prevent 
the  extension  of  the  disease.  Sterile  pads  of  gauze  or  gauze  and  cotton 
should  be  applied  frequently  enough  to  keep  them  dry.  Whenever 
the  pads  are  changed  let  the  infected  area  be  cleansed  with  sterile 
water,  dried,  and  dusted  with  boric  acid. 

In  the  subacute  or  chronic  period  the  treatment  will  follow  in  the 


VILVITIS,    VVLVOVAdlMTlS,    VAdlMTIS  187 

main  the  (lircctions  laid  down  in  the  early  jjart  of  this  chapter  on 
(General  Considerations  of  Treatment.  Intractable  cases  may  require 
a  thorough  application  of  10  to  20  per  cent,  solution  of  silver  nitrate, 
to  he  followed  innnediately  by  washing  the  parts  in  normal  salt  solu- 
tion, in  order  to  prevent  undue  caustic  action  and  consequent  cicatricial 
contraction;  as  a  safeguard  against  stenosis  or  obliterations  of  the  vagina 
by  adhesions,  it  may  be  well  frequently  to  smear  the  vulvovaginal 
surfaces  with  \aseline,  and  to  keep  the  vaginal  walls  separated  by 
means  of  light  packing. 

A  solution  of  nitrate  of  silver  may  be  used  with  excellent  efiect  as 
follows:  The  patient  being  in  the  dorsal  position,  with  the  hips  elevated, 
introduce  a  cylindrical  speculum  so  as  to  expose  the  cervix  uteri  and 
vault  of  the  vagina.  Into  this  speculum  pour  a  3  per  cent,  aqueous 
solution  of  nitrate  of  silver.  Allow  this  solution  to  bathe  the  cervix 
uteri  and  vault  of  the  ^'agina  for  five  minutes ;  then  remove  the  solution 
by  means  of  absorbent  cotton.  This  treatment  should  be  repeated  two 
or  three  times  a  week.  Argyrol  may  be  substituted  advantageously 
for  the  silver  nitrate. 

If  the  disease  has  extended  to  the  higher  zones  of  the  genito-urinary 
tract,  special  treatment  to  these  parts  will  be  required.  See  following 
chapters. 

Erysipelatous  Vulvovaginitis 

Erysipelas  is  primarily  an  inflammation  of  the  lymphatic  vessels  of 
the  skin  or  mucous  membrane.  The  infection  is  caused  by  a  strepto- 
coccus similar  to  the  streptococcus  pyogenes — perhaps  identical  with 
it.  The  disease  is  febrile,  always  acute,  often  suppurative  and  super- 
ficial, and  chiefly  characterized  by  a  tendency  to  spread,  and  occurs 
sporadically,  endemically,  or  epidemically.  There  are  three  varieties: 
the  erythematous,  the  vesicular,  and  the  gangrenous. 

The  Erythematous  erysipelas  of  the  vulva  and  vagina  is  the  mildest 
form.  It  presents  redness  and  heat  of  the  surface.  The  skin  or  mucous 
membrane  is  but  little  swollen,  and  the  tendency  is  strongly  tow^ard 
spontaneous  recovery. 

The  Vesicular  form  is  more  severe,  is  characterized  by  intense 
inflammation  of  the  skin  or  mucous  membrane,  by  marked  oedema, 
and  by  the  appearance,  under  the  surface,  of  vesicles  or  bullae,  w^hich, 
like  blisters,  contain  serum.  Finally,  infection  in  these  vesicles  may 
cause  suppuration,  and  the  inflammation  may  extend  to  the  deeper 
structures  and  become  phlegmonous. 

The  Gangrenous  or  destructive  type  is  the  most  dangerous  form  of 
erysipelatous  vulvitis.  It  apparently  results  from  rapid  development 
of  streptococci  and  their  products  in  the  lymph-channels  and  connective- 
tissue  spaces  so  as  to  shut  oft'  nutrition  and  cause  necrosis.  It  destroys 
large  areas  or  small  patches  of  skin  or  mucous  membrane  and  some- 
times deeper  structures.  Burrowing  abscesses  may  be  formed  with 
perivaginal  fluctuation.  The  musculature  of  the  vagina  and  vulva,  in 
whole  or  in  part,  may  separate  and  slough  off  in  a  gangrenous  mass. 


188      INFECTIONS,    INFLAMMATIONS,   AND   ALLIED   DISORDERS 

The  cicatricial  contraction  which  follows  will  then  cause  stenosis  or 
atresia.  It  is  often  impossible  in  such  cases  to  restore  the  caliber  of 
the  vagina  or  vulva  by  operative  measures.  Secretions  of  menstrual 
fluid  may  accumulate  above  the  atresia  in  the  vagina,  uterus,  or 
Fallopian  tubes.  This  form  of  the  disease  has  been  described  as 
jjaravaginitis  or  dissecting  vaginitis. 

Erysipelatous  vulvovaginal  inflammation  has  been  observed  in  very 
young  infants  by  extension  from  the  navel;  it  may  spread  from  the 
vulva  to  the  thighs  and  nates;  it  is  observed  sometimes  in  child- 
hood, but  is  rare  in  adults,  except  in  childbed,  where  it  is  a  most 
dangerous  affection.  Bad  nutrition  and  filth  are  strong  predisposing 
causes.  Generally  speaking  the  prognosis  is  favorable,  doubtful,  or 
grave  according  to  the  extent  and  severity  of  the  disease.  Gangrene 
of  the  vulva,  especially  in  infants,  is  almost  always  fatal. 

Treatment  does  not  differ  materially  from  that  of  the  diphtheritic 
form,  as  set  forth  in  the  following  paragraphs.  If  the  inflammation 
becomes  phlegmonous  and  results  in  suppuration,  the  abscess  should  be 
opened.  The  gangrenous  variety  calls  for  strong  supporting  measures 
and  rigid  disinfection  with  pure  carbolic  acid. 


Diphtheritic  Vulvovaginitis 

This  form  of  vulvovaginal  inflammation  rarely  appears  in  the  non- 
puerperal adult.  It  is  characterized  by  the  presence  of  a  dirty  grayish- 
white  adherent  membrane,  the  removal  of  which  leaves  a  raw  bleeding 
surface.  It  is  sometimes  the  local  manifestations  of  a  very  grave  form 
of  puerperal  fever  which  occurs  in  epidemics,  especially  in  the  obstet- 
rical wards  of  hospitals.  It  sometimes  attacks  children  during  epidemics 
of  ordinary  diphtheria.  Positive  diagnosis  will  depend  on  microscopical 
findings. 

There  are  other  milder  forms  of  membranous  vulvovaginitis  in  which 
the  germ  of  diphtheria  is  not  present — pseudodiphtheritic  vulvovaginitis. 

Diphtheritic  infection  may  give  rise  to  clinical  manifestations  not 
unlike  so-called  paravaginitis  or  dissecting  vaginitis,  described  under 
Erysipelatous  Vulvovaginitis. 

Treatment. — The  general  treatment  includes  energetic  supporting 
measures,  such  as  quinine,  the  mineral  acids,  ferric  chloride,  and  some- 
times heart  stimulants.  The  bowels  should  be  regulated,  if  necessary, 
by  mercurials  and  salines.  Local  treatment  is  of  little  value:  antitoxin 
is  the  essential  and  imperative  remedy. 


Tubercular  Vulvovaginitis — Lupus 

Tubercular  inflammation  has  been  found  in  every  part  of  the  genital 
tract,  the  order  of  frequency  for  the  various  parts  being  the  Fallopian 
tubes,  corpus  uteri,  ovaries,  vagina,  cervix  uteri,  and  vulva.     It  gives 


Vri.VITIS,    Vri.VOVMUMTIS,    VACISITIS  189 

IK)  cliariictcristic  symptoms;  the  dia^Miosis  (l('])cii(ls  upon  liiidiiifr  the 
l)acilliis  tulxTculosis  and  ii])oii  positive  reaction  ot"  tlie  tuliiTciilin  test. 
Tlie  disease  may  he  secondary  to  tulxTcnlosis  in  some  extra pehic  or^ui, 
or  may  be  primary  in  the  genitals. 

Tubercular  vulritis,  commonly  culled  lupus,  which  sometimes  is 
(lescril)e(l  as  a  neoplasm,  is  rare  and  confined  chiefly  to  the  jjeriod  of 
maturity,  and  is  mostly  confined  to  sul)jects  of  tuberculous  tendency. 
Tlu>  characteristic  lesion  is  the  formation  of  tubercles  and  nodules, 
which  undergo  cheesy  or  colloid  degeneration,  and  finally  ulceration 
and  cicatrization  with  much  increase  of  connective  tissue  throughout 
the  affected  area.  The  ulcer  is  of  red  color,  with  a  granular  base, 
is  i)urulent  and  prone  to  bleed.  It  may  be  sui)erficial  or  so  deep  as 
to  make  permanent  fistuhe  l)etween  the  l)ladder,  vagina,  and  rectum. 
The  cicatricial  contraction  which  follows  the  ulceration  may  result 
even  in  strictures  of  the  urethra,  vagina,  or  rectum.  Hypertrophic 
processes  may  or  may  not  be  associated  with  ulceration.  The  general 
thickening  and  induration  of  the  affected  part  may  be  so  extensive 
as  to  give  the  labia  the  appearance  of  elephantiasis.  The  vulva  and 
perineum  become  studded  with  nodules  of  red  or  violet  color.  Great 
chronicity  and  little  pain  are  notable  characteristics  of  the  disease. 
The  general  health  may  continue  unimpaired  for  many  years. 

The  Treatment  of  tubercular  vulvovaginitis  is  the  same  as  that  of 
tubercular  disease  elsewhere — i.  e.,  systemic  and  local.  Proper  climate, 
outdoor  life,  careful  attention  to  nutrition,  and  thorough  cauterization. 
Early  excision  of  the  diseased  part  together  with  a  layer  of  healthy 
tissue  around  it  gives  good  promise  of  radical  cure.  The  a:-ray  has  given 
most  encouraging  results. 

Mycotic  Vulvovaginitis 

Etiology. — ^lycotic  vulvovaginitis  is  most  common  in  diabetic  sub-- 
jects;  certain  fungi — mycoses — chief  among  them  the  leptothrix,  oidium 
albicans,  and  leptomitus,  often  are  found  in  the  vulvar  secretions,  and 
are  doubtless  the  exciting  cause.  Diabetic  urine  apparently  favors 
the  development  of  the  fungi,  although  the  disease  is  not  always  asso- 
ciated with  sugar  in  the  urine.  Furunculosis  often  complicates 
diabetic  vulvitis. 

Catarrh  of  the  genital  tract  and  pregnancy  are  ])redisposing  causes. 
The  micro-organism  may  be  brought  in  contact  with  the  genitals  by 
intercourse,  especially  with  a  diabetic  man.  The  fungus  may  be  carried 
on  the  finger  of  the  examiner.  Winckel  cites  two  cases  in  which  the 
infection  apparently  was  traced  to  the  touching  of  the  genitals  by 
the  hand  dusted  with  flour. 

Symptoms  and  Clinical  History. — The  swelling  of  the  vagina  may 
extend  to  the  vulva,  and  then  be  so  great  that  the  patient  can  neither 
stand  nor  walk.  The  epithelium  may  be  exfoliated  and  the  urine  cause 
pain  when  in  contact  with  the  exposed  surfaces.  The  pruritus  may  be 
extreme  and  paroxysmal  or  continuous.     The  flepressing  influence  of 


190      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

the  hypersecretion,  sleeplessness,  pain,  and  loss  of  appetite,  are  apt  to 
hasten  the  fatal  result  of  a  complicating  diabetes.  The  vulva  through- 
out has  a  coppery  red  color,  is  much  swollen,  is  dry  in  some  parts  and 
may  be  moist  in  others.  Scratching  may  cause  here  and  there  consider- 
able bleeding.  The  skin  is  dry  and  brittle,  wrinkled  and  rigid.  The 
aflPection  may  invade  the  inner  folds  of  the  nymphse,  the  meatus  urin- 
arius,  the  folds  of  the  groin,  the  mons  veneris,  and  the  folds  of  the 
nates,  and  may  surround  the  anus.  An  improvement  in  the  general 
condition  of  the  patient  may  lessen  the  local  disease,  which  is  liable 
to  return,  however,  with  increased  severity.^ 

Diagnosis. — Small  yellow  or  white  spots  sometimes  resembling  leuco- 
placia  upon  the  reddened  mucous  membrane  or  skin,  which  cannot 
be  scraped  off  without  at  the  same  time  removing  the  epithelium, 
are  characteristic  of  the  disease.  These  spots,  taken  together  with 
finding  the  micro-organism  by  microscopical  examination,  will  establish 
the  diagnosis. 

Prognosis. — The  prognosis  is  variable.  The  disease  may  be  most 
persistent  or  may  disappear  under  treatment.  In  pregnant  women  it 
may  disappear  after  delivery. 

Treatment. — If  there  is  an  associated  diabetes,  a  diabetic  dietary, 
in  addition  to  tonics  and  mild  saline  laxatives,  is  indicated  first.  The 
intolerable  itching  and  burning  necessitate  local  remedies,  of  which 
many  have  been  used  with  varying  and  temporary  success.  Wash 
thoroughly  with  a  tepid  solution  of  corrosive  sublimate,  1 :  2000,  or 
with  a  saturated  solution  of  boric  acid.  Benzoated  oxide  of  zinc 
ointment  or  an  ointment  of  vaseline  and  salicylic  acid,  1 :  200,  is  useful. 
The  sitz-bath,  temperature  80°  F.,  prolonged  for  an  hour,  often  gives 
relief;  to  this  bath  may  be  added  a  pound  of  Indian  meal.  Astringent 
washes,  for  example,  of  tannin  or  alum,  or  sulphate  of  zinc,  may  be 
indicated. 

Since  the  skin  in  mycotic  vulvitis  is  already  dry  and  brittle,  it  is  not 
well  to  dust  the  vulva  with  powder.  To  relieve  the  suffering,  which 
is  usually  worse  at  night,  place  on  the  parts  at  bedtime  a  compress 
moistened  with  a  3  per  cent,  solution  of  carbolic  acid. 

Anodynes  may  be  used  locally;  one  part  of  chloroform  to  five  parts 
of  almond  oil,  ointments  of  belladonna  and  morphine,  or  a  6  per  cent, 
solution  or  ointment  of  cocaine,  may  give  temporary  relief.  The  dis- 
ease in  a  diabetic  subject  is  usually  intractable  or  incurable.  See 
Furuncular  Vulvitis  and  Pruritus  Vulvge.  A  most  effective  applica- 
tion is  an  ointment  containing:  camphor,  4  grains;  chloral  hydrate, 
4  grains,  menthol,  |  grain;  carbolic  acid,  1  grain;  lanoline,  100  grains. 

Mycoses  of  the  vulva  and  vagina  in  subjects  not  suffering  from 
diabetes  are  usually  self-limited  or  easily  cured  by  the  treatment 
above  indicated.  The  vaginal  mycoses  require  douches  of  carbolic 
add,  3  per  cent.,  or  of  corrosive  sublimate  solution,  1:  2000. 

1  Winckel.     Diseases  of  Women. 


VrLVlTlS,    VCfA'OVAaiXITlS,    VAdlMTIS  \\)\ 

Syphilitic   Vulvovaginitis   and   Chancroid 

The  subject  includes  the  j)rimary,  secondan-,  and  tertiary  forms  of 
sypliihs. 

Chancre,  usually  single,  rarely  nuiltiple,  develops  after  an  incubation 
of  from  ten  to  twenty  days,  usually  the  latter.  It  is  first  a  reddened 
excoriated  spot  or  a  hardened  i)apule  with  or  without  ulceration.  The 
characteristic  feature  is  induration.  The  induration  may  be  parchment- 
like and  superficial,  or  it  may  be  deep  and  reach  laterally  far  beyond 
the  edge  of  the  erosion  or  ulceration.  The  indurated  tissue  is  hard, 
like  cartilage,  but  seldom  so  pronounced  in  women  as  in  men.  In  the 
ulcerative  form  the  ulcer  is  usually  small  and  funnel-shaped,  with 
sloping  edges,  superficial  or  deep;  the  edges  are  never  undermined. 
The  bottom  of  the  ulcer  is  gray,  the  discharge  seropurulent  and  never 
free.  Rarely  more  than  one  chancre  ever  appears  in  the  same  person. 
The  inguinal  glands  usually  enlarge,  but  except  in  cases  of  mixed  infec- 
tions do  not  suppurate.  Chancre  is  only  the  local  sign  of  syphilis,  and 
its  pus  is  rarely,  if  ever,  auto-inoculable. 

The  Secondary  and  Tertiary  Lesions  of  Syphilis-  include  mucous 
patches  and  gummata.  These  patches  on  the  genitals  have  the  same 
general  character  as  when  they  appear  elsewhere.  In  the  second 
stage  flat  condylomata  form.    See  Chapter  XXII. 

Chancroid,  which  is  a  purely  local  infection,  has  no  period  of  incu- 
bation, is  auto-inoculable,  has  a  rounded  or  oval  margin,  abrupt  or 
ragged  edges,  no  induration,  and  may  develop  into  a  large  or  phagedenic 
ulcer.  The  inguinal  glands  are  prone  to  suppurate.  Large  numbers 
of  chancroids  may  occur  on  the  same  person. 

Treatment. — The  treatment  is  that  of  syphilis  or  chancroid  as  the 
case  may  be.  The  local  lesions  may  be  complicated  with  other  forms 
of  vulvovaginitis,  which  should  have  special  attention  according  to 
their  class. 

SPECIAL    ANATOMICAL    FORMS    OF   VULVOVAGINITIS 

Superficial  Vulvitis  and  Vaginitis 

This  sometimes  is  called  simple  inflammation.  When  acute  it  often 
produces  mild  systemic  fever  and  sometimes  excessive  swelling,  pain, 
and  irritation.  The  disorder  is  erythematous  and  resembles  urticaria. 
It  does  not  give  rise  to  much  exudate,  is  not  very  virulent,  and  seldom 
or  never  extends  to  the  follicular  or  glandular  elements  or  to  the  uterus. 
It  tends  to  rapid  resolution  on  removal  of  the  irritating  cause.  It 
often  causes  excessive  oedema  of  the  labia  minora,  which  oedema  may 
disappear  in  a  few  hours. 

The  causes  of  superficial  vulvitis  and  vaginitis  are  often  largely 
mechanical,  such  as  masturbation,  excessive  coitus,  rubbing,  scratching. 
Pinworms,  tsenia  circinata,  and  irritating  vaginal  or  uterine  discharges 
are  among  the  other  causes.     The  inflammation  may  be  in  the  form 


192      INFECTIONS,   INFLAMMATIONS,   AND   ALLIED   DISORDERS 

of  vulvitis,  vulvovaginitis,  or  vaginitis.  It  does  not  involve  the  corium 
in  the  vulva  nor  the  submucosa  in  the  vagina.  The  treatment  has  been 
described  in  the  general  therapeutics  of  vulvovaginal  inflammation. 

Senile   Vulvo vaginitis 

Senile  vulvovaginitis  is  usually,  though  not  always,  a  somewhat 
deep  inflammation.  The  retrogressive  physiological  processes  of  the 
menopause  which  result  in  senile  atrophy  of  the  reproductive  organs 
destroy  in  great  part  the  epithelial  portion  of  the  mucous  membrane 
of  the  uterus,  vagina,  and  vulva,  so  that  this  membrane  becomes  com- 
posed largely  of  fibrous  tissue.  This  fibrous  tissue  when  inflamed  is 
prone  to  granulate,  to  suppurate,  to  cicatrize,  to  contract,  and  to  form 
adhesions  of  any  surfaces  in  contact  with  one  another.  vStenosis  at  the 
internal  or  external  os  uteri  may  prevent  free  drainage  of  the  uterine 
secretions.  These  secretions,  already  pathological,  when  retained 
become  excessively  irritating.  Similar  secretions  also  come  from  the 
vagina  and  vulva.  Aged  women,  therefore,  who  have  long  passed 
the  menopause,  are  subject  to  a  most  irritating  vulvovaginitis — a  most 
exhausting  and  distressing  pruritus  vulvae.  The  adhesions  often 
entirely  envelop  the  vaginal  portion  of  the  cervix  and  may  obliterate 
partially  the  vagina.  The  vulvar  glands  and  mucous  crypts,  especially 
in  pruritus  cases,  are  involved  extensively.  Removal  of  them  is  the 
only  means  of  relief  from  the  intolerable  itching  and  burning.  See 
Treatment  of  Glandular  Vulvitis.  In  other  respects  the  treatment  is 
the  same  as  that  laid  down  in  the  general  therapeutics  of  vulvovaginal 
inflammation. 

Not  infrequently  especially  as  the  menopause  approaches  and  pro- 
gresses there  is  a  very  irritating  acid  discharge  from  the  genital  tract, 
which  may  or  may  not  be  associated  with  menstruation.  It  was  thought 
that  such  a  discharge  may  have  close  relationship  with  deficient  alka- 
linity of  the  blood,  and  that  alkalies,  therefore,  such  as  sodium  carbonate, 
vichy,  and  other  saline  waters  may  fulfil  a  definite  indication. 

Glandular  Vulvitis 

Inflammation  of  the  Urethral  Crypts. — Five  or  six  small  racemose 
glands  are  situated  around  the  meatus  urinarius.  They  have  short 
ducts  with  wide  openings;  two  of  them  are  in  little  depressions  on  either 
side  of  the  meatus.  Inflammation  in  these  glands  or  crypts,  not  un- 
common during  and  after  the  menopause,  may  cause  a  most  persistent 
pruritus  with  extreme  itching  and  burning;  this  occurs  most  frequently 
in  connection  with  senile  vulvitis. 

Inflammation  of  the  Vulvovaginal  Glands. — The  ruhomginal  glands 
of  Bartholin  are  on  either  side  of  the  vaginal  oriflce  near  the  posterior 
extremity  of  the  bulb  of  the  vagina.  Their  ducts  are  about  one-half 
inch  long  and  open  into  the  fossa  navicularis,  where  they  are  seen  easily. 

Inflammation  of  these  glands  comes  bv  extension  from  the  external 


VULVITIS,    VriAOWUIIMTIS,    VAdlMTlS 


li>3 


surface.  Tlie  <,Maii(ls,  or  tlii'ir  allerent  (hicts,  or  both,  may  he  involved. 
A  suppurating  gland  may  pour  out  pus  through  the  duct;  or  the  duct 
may  close  by  adhesive  inflammation  and  form  an  abscess;  it  may 
become  occluded  and  distended  with  the  normal  secretion  of  the  gland, 


FiiiuuE  so 


Fig u KB  SI 


Figure  82 


Figure  SO. — Enlargement  of  the  vulvovaginal  gland  by  cyst :  an  abscess  would  have  a  similar  appear- 
ance, but  unlike  the  cyst  would  he  painful  on  pressure. 

Figure  81. — Cyst  wall  dissected  out;  wound  held  open  by  tenacula:  introduction  of  first  suture 
for  closure  of  thewound;  silkworm-gut  suture;  a  small  tubal  or  gauze-wick  drain  is  useful  in  the.^e 
cases. 

Figure  S2. — Wound  closed  with  fine  silkworm-gut  sutures. 

Figure  83. — Right  inguinal  hernia  simulating  vulvovaginal  cyst  or  abscess. 

13 


194      INFECTIONS,   INFLAMMATIONS,    AND   ALLIED   DISORDERS 

and  thus  form  a  retention-cyst.  One  or  both  glands  may  be  affected. 
The  disease  is  very  common.  Sanger  describes  a  red  areola  (macule) 
about  the  openings  of  the  ducts  as  an  evidence  of  gonorrhoea. 

Diagnosis. — Abscess  is  distinguished  from  retention-cyst  of  the 
glands  by  the  presence  of  acute  pain  and  heat  in  the  former  and  the 
absence  of  them  in  the  latter.  Enlargement  of  the  gland  under  either 
of  these  conditions  is  distinguished  from  phlegmonous  vulvitis  by 
the  location  of  the  former,  which  corresponds  to  that  of  the  gland, 
while  phlegmon  may  be  am'where  in  the  vulva;  and  from  hernia  by 
the  absence  of  the  characteristic  signs  of  hernia  and  by  the  location. 

Glandular  vulvitis,  once  established,  becomes  chronic.  The  glands 
serve  as  culture-ground  for  the  infecting  bacteria,  hence  superficial 
\nalvovaginitis,  though  apparently  cured,  may  recur  again  and  again 
from  the  infected  glands.  The  vulva,  through  its  glandular  structures, 
is  a  great  distributing  point  of  pelvic  infection.  The  periodical  con- 
gestion of  menstruation  is  a  recognized  predisposing  cause  of  recurring 
pelvic  inflammation.  As  stated  elsewhere,  the  capacity  of  glandular 
structures  to  receive,  retain,  and  distribute  infection  often  will  explain 
the  frequently  observed  attacks  of  recurrent  gonorrhoea  in  women. 

The  explanation  of  so-called  latent  gonorrhoea  in  the  male,  discussed 
by  Xoeggerath,  is  the  same  as  that  given  in  the  preceding  paragraph 
for  recurrent  gonorrhoea  in  women. 

The  Treatment  of  Glandular  Vulvitis,  when  acute  and  non-suppura- 
tive,  is  palliation  and  cleanliness,  the  latter  to  be  secured  chiefly  by 
disinfectants.  When  the  inflammation  is  chronic,  the  treatment  varies 
with  the  different  glands,  as  follows: 

The  five  or  six  small  mucous  crypts  near  the  meatus  urinarius, 
when  infected,  are  the  seat  of  an  intolerable  pruritus.  The  treatment 
is  to  destroy  the  glands  by  the  actual  cautery  or  to  remove  them  by 
excision.  The  author's  preference  is  to  excise  them,  close  the  wounds 
by  suture,  and  secure  union  by  first  intention. 

The  treatment  of  abscess  of  a  vulvovaginal  gland  is  the  same  in 
principle  as  for  abscess  elsewhere ;  it  should  be  opened  widely,  the  wound 
packed  with  gauze,  and  made  to  heal  from  the  bottom  by  granulation. 
In  opening  the  abscess  find  the  gland,  if  possible,  and  remove  it. 

When  a  retention-cyst  has  formed  from  occlusion  of  the  duct,  the 
sac  should  be  dissected  out,  the  wound  sutured,  and  for  one  or  two 
days  drained  with  a  small  rubber  tube  or  with  gauze  wick.  If  drainage 
is  not  used,  the  wound  is  liable  to  suppurate. 

Sometimes  chronic  suppuration  of  the  gland  occurs  through  the 
open  duct.  Then  the  duct  should  be  incised  widely,  the  gland  removed, 
and  the  wound  packed  with  gauze. 

Follicular  Vulvitis 

The  labia  minora  and  majora  are  supplied  abundantly  with  hair- 
bulbs,  sebaceous  follicles,  and  sweat-follicles.  Inflammation  in  these 
structures  of  an  acne-like  character  is  the  term  applied  to  follicular 


VULVITIS,    VVLVOVAdlXITIS,    VACIXITIS 


195 


vulvitis  or  folliciilltis.  Figure  <S4.  The  general  appearance  of  the  sur- 
face, except  slij^ht  C()iitj;('sti()ii,  usually  is  uiichan<!;ed.  The  openings  of 
the  follicles  scattered  o\er  the  lal)ia  minora  and  niajora  are  small,  red, 
elevated,  and  swollen.  Children  are  not  subject  to  folliculitis.  The 
iiiHanunation  may  originate  in  the  follicles  or  may  extend  to  themirom 
the  external  surface,  as  in  glandular  vulvitis.  The  infection  often 
remains  entrenched  in  the  follicles  after  it  has  disappeared  from  the 
external  surface,  and  from  these  lurking-places  may  reinfect  the  surface 
again  and  again. 

Figure  84 


Follicular  \'-uh'iti3. 


Adhesive  inflammation  may  close  the  openings  of  the  ducts;  then 
the  secretions  will  be  retained  and  form  abscesses  as  large  as  a  pea; 
otherwise  the  discharge  is  abundant,  purulent,  and  often  offensive. 

Treatment. — The  disease  may  be  seated  so  deeply  that  it  resists  all 
surface  applications,  and  yields  only  to  direct  deep  cauterization 
strong  enough  to  destroy  the  secreting  structures.  For  this  purpose, 
use  the  fine  galvanocautery  needle  or  the  point  of  a  probe  made  red- 
hot  in  the  flame  of  a  spirit-lamp. 

In  follicular  vulvitis  with  occlusion  open  each  follicle  with  a  small, 
sharp-pointed  knife,  and  then  apply  the  fine-pointed  conical  solid  stick 
of  nitrate  of  silver.     This  may  be  done  under  cocaine  without  pain. 


196      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

A  dressing  of  sterile  gauze  saturated  with  formalin,  1 :  1000,  placed  as  a 
pad  over  the  vulva,  is  a  most  serviceable  application.  The  a;-rays  are 
used  with  surprisingly  good  results. 

Furunculosis  differs  from  the  usual  follicular  vulvitis,  since  it  usually 
starts  in  the  hair-follicles  and  extends  to  the  surrounding  cellular  tissue. 
The  resultant  boil  may  be  developed  at  numerous  points  in  the  labia 
majora,  where  the  disease  usually  is  confined.  Some  women  have  an 
unexplained  tendency  to  this  form  of  vulvitis.  Furunculosis  is  common 
in  diabetes.  The  author  has  observed  that  glycerin  tamponade  is  often 
possibly  an  exciting  cause  of  boils.  The  incipient  boil  may  often  be 
aborted  by  pulling  out  the  hair  from  the  inflamed  hair  bulb,  thereby 
giving  drainage. 

The  Treatment  of  furunculosis  is  the  same  in  the  vulva  as  elsewhere 
— i.  e.,  open  and  drain  the  abscess.  Numerous  boils  sometimes  follow 
one  another,  or  occur  in  successive  clusters  in  one  locality.  Such  re- 
curring infection  is  due  usually  to  the  presence  of  the  microbes  of 
suppuration,  which  remain  on  the  surface  ready  to  produce  reinfec- 
tion at  any  favorable  point.  Daily  cleansing  of  the  surface  and 
thorough  disinfection  with  the  ointment  of  biniodide  of  mercury  (1 :  60) 
for  two  weeks  after  the  last  boil  has  disappeared  are  effective  means 
of  prophylaxis.  The  a;-rays  are  most  efficacious.  General  tonics  are 
decidedly  indicated.  Fresh  brewers'  yeast  taken  in  wineglassful  doses, 
four  or  five  times  a  day,  is  a  most  useful  remedy.  Autogenous 
vaccines  have  given  curative  results. 

Emphysematous  Vaginitis 

This  rare  disease,  doubtless  due  to  one  of  the  gas-forming  bacilli, 
occurs  mostly  in  pregnancy.  It  is  characterized  by  numerous  small, 
soft  cysts  of  variable  size  situated  just  under  the  surface  and  commonly 
on  the  posterior  wall  of  the  vagina.  These  cysts  contain  serous  fluid 
and  gas.  The  affection  usually  is  associated  with  other  forms  of  vaginitis. 
The  diagnosis  may  be  verified  by  pricking  the  cysts;  then  the  gas  escapes 
with  a  blowing  sound.  In  pregnant  women  the  cysts  disappear  without 
treatment  at  the  end  of  pregnancy. 

Treatment. — In  puerperal  cases  the  treatment  is  expectant.  In  non- 
puerperal cases,  if  the  cysts  do  not  disappear  under  antiseptic  douches, 
they  should  be  opened  and  the  vagina  packed  with  antiseptic  gauze. 


CHAPTER  XTT 

ECZEMA    M'LV.E,    HERPES   VULV.E,   KRAUROSIS    VULV.E, 

PRURITUS  VULV.E,   HYPER.ESTHESIA   VULVAE, 

VAGIXIS^ilUS 

Amox(;  the  disorders  allied  to  vulvovaginal  inflammation  are  eczema 
vulvae,  herpes  vulva?,  kraurosis  vulvte,  pruritus  vulva?,  and  vaginismus. 


ECZEMA   VULV^ 

Eczema  vulvae  is  an  infrec^uent  disease,  may  be  acute  or  chronic, 
and  occurs  mostly  during  pregnancy.  Rheumatic  and  gouty  subjects 
are  said  to  be  predisposed.  The  eruption  consists  of  nodules,  vesicles, 
pustules,  and  crusts,  with  more  or  less  redness,  swelling,  and  moisture 
of  the  skin.  The  vesicles  contain  serous  fluid.  Pus  is. found  under  the 
crusts  in  the  more  severe  cases.  The  skin  and  sometimes  the  subcu- 
taneous tissues  are  infiltrated.  Acute  eczema  may  remain  local  and 
terminate  within  two  weeks.  Chronic  eczema,  often  intractable,  may 
extend  to  the  mons  veneris,  thighs,  and  nates,  with  swelling  and 
suppuration.  The  labia  majora  most  commonly  are  involved.  The 
subjective  symptoms  are  intense  itching  and  burning — rarely  acute  pain. 

Treatment  of  Eczema  Vulvse 

The  general  treatment  consists  of  mercurials  and  salines,  non-irri- 
tating diet,  avoidance  of  wine  and  liquor,  and  hygienic  living.  The 
local  treatment  varies  with  the  condition.  ^Mienever  the  subcutaneous 
structures  are  exposed,  the  solid  nitrate  of  silver  point  should  be  applied, 
care  being  taken  to  touch  only  the  exposed  surfaces.  Oftentimes 
numerous  very  minute  abrasions  may  be  seen  with  the  unaided  eye 
or  through  a  magnifying-glass.  These  should  be  touched  delicately 
with  the  finest  point  of  nitrate  of  silver.  The  application  should  be 
repeated  every  five  days  until  the  abrasion  disappears.  The  following 
ointment  is  useful: 

Ointment  of  rose  water 1  ounce 

Lanoline 2  drachms 

Oxide  of  zinc 1  drachm 

Boric  acid 1  drachm 

Ammoniated  ichthyol 40  grains 

Thymol 5  grains 

The  parts  should  be  kept  dry  and  clean.  Dusting  with  bismuth, 
zinc  oxide,  boric  acid,  and  calomel  may  give  relief. 

(197) 


198      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 
The  following  lotion  is  very  efficacious: 

Zinc  oxide 4  drachms 

Boric  acid 6  drachms 

Talc 4  drachms 

Carbolic  acid,  95  per  cent 1  drachm 

Rose  water 8  ounces 

Lime  water ad  8  ounces 

Sig. — Shake  before  using.     Apply  locally  with  saturated  gauze,  repeating  the  application  at  inter- 
vals of  a  few  minutes  until  a  deposit  is  formed  by  evaporation  over  the  affected  parts. 

Alkaline  mineral  waters  are  approved  as  part  of  the  general  treatment. 
In  chronic  cases  the  .r-ray  is  useful. 

HERPES   VULV^ 

An  herpetic  eruption,  not  unlike  herpes  labialis,  is  observed  occa- 
sionally upon  the  vulvar  labia.  There  is  little  redness  or  swelling. 
The  disease  is  of  systemic  origin,  usually  self-limited,  like  herpes  in 
other  places,  runs  its  course  in  a  few  days,  and  disappears. 


KRAUROSIS   VULV^ 

Kraurosis  vulvae  is  a  rare  disease  of  unknown  cause  characterized 
by  atrophic  shrinking  of  the  vulva,  especially  the  inner  surface  of  the 
nymphae. 

Pathology  of  Kraurosis  Vulvae 

The  pathology  of  this  disease  is  not  fully  known.  The  following 
changes  are  present:  dry,  shrunken  skin,  tense,  glistening,  scar-like 
surface;  hair  around  the  vulva  thin,  dry,  and  late  in  the  disease  almost 
entirely  absent.  Finally,  extreme  shrinking  and  rigidity  of  the  vulva, 
sometimes  almost  to  the  point  of  occlusion.  Paleness  and  absence  of 
pigment  in  the  skin,  which  may  be  studded  with  numerous  irregularly 
reddish-brown  blood  spots,  which  on  inspection  appear  slightly  depressed 
below  the  surface.  These  spots  are  confined  entirely  to  the  vestibule 
and  disappear  in  the  later  stages  of  the  disease  and  are  followed  by 
cracking  and  abrasion  of  the  skin,  which  occasionally  may  give  forth 
a  slight,  brown,  purulent  discharge. 

Longyear  has  observed  a  deep  cirrhotic-like  band  of  fibrous  tissue 
entirely  distinct  from  the  cutaneous  covering.  He  regards  this 
band  as  the  essential  lesion,  and  gives  to  the  superficial  changes 
a  secondary  importance;  it  replaces  the  loose  cellular  tissue  through 
which  the  nutrient  vessels  pass  to  the  skin,  and  by  its  gradual  and  con- 
tinual contraction  causes  not  only  the  vulvar  shrinkage,  but  also  the 
strangulation  of  the  blood-vessels  which  pass  to  and  from  the  overlying 
cutaneous  structures.  This  disturbance  in  circulation  explains  the 
spots  of  ecchymosis  in  the  earlier  and  the  atrophic  changes  in  the  later 
stages.  The  pain  is  explained  by  mechanical  pressure  on  the  nerves 
and  by  the  resultant  neuritis  and  perineuritis.  Kraurosis  in  a  small 
proportion  of  cases  is  associated  with  epithelioma  of  the  vulva. 


k'i;.\rn()sis  vilv.^  VM) 

Symptoms  and  Diagnosis  of  Kraurosis  Vulvae 

The  crmical  fcaliircs  arc  so  cliaractcrist ic  lliat  oiur  recognized  they 
\vill  not  be  niistaki-n  for  anotlier  disease.     TluTe  are  distressiii},^  par- 


A.  radical  operation  for  kraurosis  or  pruritus  vulva.  The  black  and  white  dotted  lines  indicate 
the  direction  of  the  incisions  in  the  radical  operation  for  kraurosis  or  pruritus  vulva;.  1  he  inner  inci- 
sion in  extreme  cases,  involving  the  lower  part  of  the  vagina,  especially  kraurosis,  would  usually  have 
to  include  the  introitus  vagina.  B.  disea.sed  structures  removed  C,  three  sutures  in  p  ace  and  tied, 
one  suture  being  introduced.     D.  operation  being  completed  by  the  introduction  of  the  last  suture. 

oxysms  of  itching  and  burning  of  the  outside  parts,  especially  when 
the  brown  spots  mentioned  under  pathology  are  present.    These  symp- 


200      ISFECTIONS,    INFLAMMATIONS,   AND  ALLIED  DISORDERS 

toms  taken  together  with  the  pathological  appearance  mentioned  above 
will  establish  the  diagnosis. 

Kraurosis  in  a  small  proportion  of  cases  is  associated  with  epithe- 
lioma of  the  vulva. 

Treatment  of  Kraurosis  Vulvae 

This  new  formation  of  fibrous  tissue  is  of  special  interest  from  the 
surgical  standpoint.  Clearly  the  removal  of  this  band,  together  with 
the  contracted  superficial  structures,  is  essential  to  the  cure  of  the 
disease.  The  usual  operation  of  removing  the  degenerated  and  con- 
tracted mucocutaneous  structures  may  relieve  the  acute  symptoms, 
but  can  have  no  effect  on  the  stenosis.  Spontaneous  recovery  some- 
times is  reported;  but  this  is  only  a  relief  from  the  supersensitiveness 
of  the  vulva,  never  from  the  constriction.  The  fibrous  band,  unless 
removed  by  operation,  is  permanent.  Longyear's  operation  is  the 
removal  of  all  the  superficial  diseased  structures,  together  with  the 
fibrous  band  beneath,  and  union  of  the  external  and  internal  margins 
of  the  w^ound.  An  incision  with  scissors  is  made  first  along  the  lateral 
and  posterior  margins  of  the  vulvar  orifice,  dividing  the  diseased  struc- 
tures from  the  healthy  skin;  then  the  margin  of  the  diseased  tissue, 
including  the  fibrous  band,  is  seized  with  dressing-forceps  and  dis- 
sected loose  from  the  underlying  tissues  to  the  vaginal  inlet.  This 
tissue  then  is  cut  away.  The  anterior  vulvar  structures  are  dissected 
loose  in  the  same  manner,  care  being  taken  to  cut  carefully  around  the 
urethral  orifice.  After  removing  all  the  diseased  structures  in  this 
way  the  margin  of  the  healthy  vaginal  wall  above  is  pulled  down  and 
dissected  loose  from  the  underlying  parts  around  the  whole  circum- 
ference of  the  vagina.  This  loosening  of  the  vaginal  wall  permits  the 
inner  margin  of  the  wound  to  be  brought  down  to  the  outer  margin. 
The  two  margins  then  are  united  with  deep  silkworm  gut  and  super- 
ficial catgut  sutures,  or  with  fine  buried  chromic  catgut.  Complete 
relief  has  followed  the  operation.  The  operation  is  similar  to  that 
illustrated  under  the  surgical  treatment  of  Pruritus  Vulvae  in  this 
chapter, 

NEUROPATHIC   PRURITUS   VULV^ 

Neuropathic  neurotic  women  are  subject  to  an  exaggerated  pruritus, 
that  is,  an  intense  intolerable  intractable  irritation,  itching  and  burning, 
which  characteristically  recurs  at  intervals  as  a  paroxysmal  wave  of 
great  violence. 

The  neurotic  element,  whether  causal,  resu  tant,  or  concurrent,  has 
not  been  explained  adequately.  Vulvitis,  herpes,  and  other  irritating 
affections  of  the  vulva,  although  quite  commonly  associated  with 
neuropathic  pruritus  and  greatly  aggravating  it,  and  doubtless  having 
much  influence  as  exciting  causes,  are  not  essential  to  it;  indeed,  may 
be  insignificant  or  apparentl}^  absent.     For  these  reasons  the  disease 


M-:ri!()i\iTiiic  I'liriirrrs  vri.v.K  •10\ 

has  been  classed  as  a  neurosis.  An  cliisiNC  clciiicnl  tn  he  taken  into 
account  is  what  (looih-ll  a|)tly  caHcd  the  in\isil)l(',  intan^ihlc,  ini|)on(lcr- 
ahh*  inlhicncc  of  the  nt-r\()US  system.  The  essential  factor  is  neim^tic 
I)rt>(lis{)()sition  to  hypera'sthesia  and  irritation  of  the  sensory  ncr\c 
organs  of  the  skin,  a  condition  of  which  our  present  knowledge  is 
incomplete.    The  affection  is  not  a  disease  hut  a  syniptoni-coniph-x. 


Etiology  of  Neuropathic  Pruritus  Vulvae 

Predisposing  Causes. — The  numerous  attempts  to  explain  the  causa- 
tion sometimes  have  made  up  in  scientific  elaboration  what  they  have 
lacked  in  clinical  value.  As  stated  above  the  essential  predisposini,^ 
cause  is  neuropathic. 

Exciting  Causes. — Certain  local  lesions  usually  are  present  which 
accoriliny;  to  the  point  of  view  may  be  regarded  as  the  exciting  causes, 
favoring  conditions  or  complications.    They  are  as  follows: 

Circulator  11  Causes  have  been  attributed  to  certain  disorders — icterus, 
diabetes,  chronic  nephritis — in  which  the  blood  contains  bile,  urea, 
or  sugar,  all  of  which  by  action  on  the  nerve  endings  are  said  to  cause 
itching.  Similar  effects  are  observed  from  the  ingestion  of  morphine, 
alcohol,  iodoform,  and  from  certain  foods,  notably  shell-fish.  Stasis 
hypera?mia  from  any  cause  occurring  in  the  region  of  the  pudendal 
and  hemorrhoidal  veins  may  be  associated,  with  erythema,  herpes, 
urticaria,  and  other  irritating  skin  disorders  "which  gi^'e  rise  to  intense 
pruritus.  Thermic  causes  are  well  authenticated  by  those  who  have 
experienced  the  intolerable  distress  of  a  disorder  known  as  pruritus 
hiemalis  in  the  winter  and  pruritus  cestimlis  in  the  summer. 

Secretory  Causes. — Abnormal  secretions  of  the  vulva,  vagina,  or 
uterus,  especially  if  combined  with  the  above-mentioned  causes,  may 
produce  great  irritation  in  the  terminal  sensory  nerves  of  the  vulva. 
Secretions  from  the  diseased  bowel  or  anus  by  chemical  action  may 
produce  pruritus  ani  and,  by  extension,  give  rise  to  pruritus  "\T.ilvae. 

Parasitic  Causes. — Animal  parasites,  such  as  pediculi  and  ascarides, 
and  vegetable  parasites,  such  as  leptothrix,  oidium,  and  leptomitus,  and 
the  ordinary  bacteria  of  inflammation,  have  been  presented  under 
Vulvovaginitis. 

Mechanical  Causes  include  masturbation,  immoderate  handling,  and 
scratching. 

Cons-tipation. — Intolerable  itching  of  the  anus  is  a  frequently  recog- 
nized accompaniment  of  habitual  constipation,  and  often  is  associated 
with  pruritus  vulvae  and  hemorrhoids.  This  may  be  explained  by  the 
fact  that  the  vulva  is  supplied  by  the  same  nerves  that  supply  the 
anus.  The  intestinal  toxins  which  have  been  recognized  as  a  cause  of 
pruritus  ani  therefore  may  cause  pruritus  vulva^  also. 


202      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

Pathology 

The  affection  as  above  stated  is  not  a  disease  but  a  "symptom 
group,"  of  which  the  essential  pathology  is  unknown. 

Diagnosis  and  Prognosis  of  Pruritus  Vulvae 

Diagnosis. — The  irritation  is  apt  to  occur  in  paroxysmal  waves. 
The  paroxysms  may  recur  after  vigorous  exercise,  especially  in  warm 
weather,  before  or  after  menstruation,  or  upon  exposure  to  artificial 
heat.  In  some  cases  they  appear  upon  getting  into  a  warm  bed.  Sexual 
excitement  and  orgasms  may  occur.  The  desire  to  rub  or  scratch  for 
the  relief  of  the  irritation  is  almost  irresistible.  This  instinctive  effort 
at  counter-irritation  greatly  aggravates  the  pruritus.  As  Thomas 
aptly  remarks,  "The  disease  and  the  remedy  which  instinct  suggests 
react  upon  one  another,  the  first  requiring  the  second,  and  the  second 
aggravating  the  first,  until  a  most  rebellious  and  deplorable  condition 
is  developed;  the  patient,  bereft  of  sleep  by  night  and  tormented 
constantly  by  day,  finally  gives  way  to  depondency  and  depression." 
The  loss  of  sleep,  the  use  and  abuse  of  anodynes,  and  the  neurosis 
incident  to  the  disease  may  contribute  to  the  development  of  the 
melancholia  or  some  other  form  of  insanity.  The  pruritus  may  extend 
to  the  vagina,  anus,  thighs,  and  abdomen.  In  some  cases  the  irritation 
begins  in  the  anus. 

Pruritus  being  not  a  disease,  but  a  symptom,  the  diagnosis  must 
depend  upon  the  identification  of  the  causative  lesion.  Insofar  as  the 
disorder  depends  upon  tangible  and  visible  conditions  the  diagnosis 
may  follow  along  the  lines  laid  down  in  Chapter  XL,  on  Vulvitis.  A 
clear  appreciation  of  the  special  etiology  of  the  disorder  as  given  above 
may  open  the  way  to  accurate  diagnosis.  Without  great  care  the 
examination  may  fail  to  disclose  the  point  and  source  of  irritation. 
An  irritating  discharge,  for  example,  so  slight  as  to  be  unknown  or 
ignored  by  the  patient,  may  be  sufficient  to  set  up  the  most  distressing 
pruritus,  and  may  therefore  have  the  utmost  significance.  In  the  vast 
majority  of  cases  one  or  more  of  the  following  conditions  will  be  found 
present,  and  will  explain  partially  or  wholly  the  irritation: 

Vulvitis.  Ichorous  discharge  from  cancer. 

Vaginitis.  Incontinence  of  urine. 

Endometritis.  Pathological  urine. 

Urethritis.  Intestinal  disease. 

Urethral  caruncle.  Vulvar  eruptions. 

Parasites.  Onanism. 

Most  commonly  associated  with  pruritus  are  vulvitis,  vaginitis,  and 
endometritis.  The  fact  that  these  diseases  do  not  commonly  produce 
the  disorder  is  explained  by  the  absence  of  the  essential  neurosis. 
Senile  vulvovaginitis  is  associated  often  with  excessive  irritation,  and 
then  is  exceedingly  obstinate. 


NEUROPATHIC   I'nnUTVS    VULV.E  203 

Prognosis.  The  pruritus  of  prc'<;ii;inc>-  and  the  in('n(ii)iiuse  is  limited 
coiuniouly  to  those  states.     In  fjeneral  the  prognosis  is  indeterminate. 

Treatment   of  Pruritus   Vulvae 

A  multipJicity  of  remedies  reeommended  in  the  therapy  of  any 
disorder  may  he  taken  as  evidence  tliat  our  resources  are  Hmited  or 
tliat  the  (Hsorder  may  result  from  one  or  more  of  a  wide  variety  of 
pathological  conditions.  Both  of  these  propositions  are  true  of  pruritus 
vulva\  The  general  treatment  is  most  important  and  is  substantially 
the  same  as  the  treatment  of  neurasthenia. 

In  many  cases  the  irritation  is  a])parently  the  outcome  of  pent-up 
sexual  energy.  A  neurotic  woman  wiio  suffers  intensely  from  pruritus 
has  experienced  entire  relief  upon  the  return  of  her  husband  from  a 
prolonged  absence. 

It  is  clear  that  the  treatment  must  be  directed  to  the  cause  of  the 
irritation;  to  this  end  the  reader  is  referred  to  the  therapy  of  vulvo- 
vaginitis and  of  the  numerous  diseases  and  disorders  already  mentioned 
under  Etiology  and  Diagnosis.  See  especially  the  treatment  of  senile 
and  mycotic  vulvovaginitis;  in  the  treatment  of  the  latter  is  the  formula 
of  an  ointment  containing  camphor,  chloral  hydrate,  menthol,  carbolic 
acid,  and  lanoline,  which  may  be  used  to  advantage  in  various  forms  of 
pruritus.     See  index  for  reference  to  aluminum  acetate. 

Palliative  measures  always  are  demanded  for  the  immediate  relief 
of  urgent  symptoms.  Fortunately,  most  of  these  measures,  since  they 
allay  irritation,  are  in  a  degree  curative.  Sitz-baths  and  vaginal  douches 
of  water  or  antiseptic  solutions  are  useful  to  remove  irritating  dis- 
charges. The  following  local  applications  may  give  relief:  the  surfaces 
after  each  bath  may  be  dried  and  freely  dusted  with  calomel,  bismuth, 
starch,  or  lycopodium  powder.     The  calomel  is  generally  preferable. 

A  vaginal  tampon  of  gauze  often  will  protect  the  vulva  from  the 
discharge,  and  thereby  give  temporary  relief.  Great  relief  sometimes 
is  experienced  from  a  gauze  compress  over  the  vulva,  saturated  with 
dilute  solution  of  subacetate  of  lead  and  laudanum,  ec{ual  parts.  The 
compress  should  be  changed  frequently. 

A  compress  saturated  with  a  solution  of  corrosive  sublimate,  1 :  1000, 
or  some  form  of  mercurial  inunction  will  act  as  if  by  magic  when  the 
cause  is  parasitic.  Cloths  wrung  out  in  very  hot  water  and  applied 
to  the  vulva  may  relieve  or  prevent  the  paroxysm  which  comes  on  after 
going  to  bed.  A  strong  infusion  of  tobacco,  according  to  Thomas, 
both  as  a  vaginal  douche  and  on  the  \^ilvar  compress,  is  most  efficacious. 
In  cases  in  which  the  neurotic  element  prevailed,  he  observed  prompt 
and  complete  relief  from  the  smoking  of  tobacco. 

Ointments  are  useful  from  the  soothing  effect  of  their  constituents 
and  because  they  protect  the  parts  from  contact  with  irritating  dis- 
charges. They  are  also  an  excellent  vehicle  for  the  application  of 
parasiticides.     See  Treatment  of  Vulvitis. 

In  rare  cases  the  pruritus  is  due  to  a  growth  of  short,  stiff,  inverted 
hair  on  the  labia  majora  or  pubes.      This  condition  is  called  trichiasis. 


204      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

Prompt  and  permanent  relief  follows  remo\'al  of  the  hairs  and  destruc- 
tion of  their  bulbs  by  electrolysis. 

The  treatment  of  the  disorder,  if  due  to  diabetes,  nephritis,  or 
icterus,  must  include  the  appropriate  therapeutic  measures,  especially 
diet.  Highly  seasoned  and  highly  nitrogenous  food  and  stimulating 
beverages  aggravate  the  irritation,  and  should  be  avoided. 

Painting  the  vulva  with  pure  ichthyol  has  been  known  to  effect  a 
radical  cure.  In  a  case  observed  by  the  writer  an  accidental  applica- 
tion of  pure  carbolic  acid  was  followed  by  permanent  cure. 

There  is  danger  of  forming  the  habit  of  using  cocaine,  morphine, 
or  other  narcotics;  for  this  reason  their  use  should  be  guarded  with 
judgment.    Avoid  scratching  or  rubbing  of  the  parts. 

The  dermatologists  have  had  great  success  in  pruritus  by  using  the 
x-rays.  It  never  fails  to  alleviate  and  generally  a  few  exposures  cause 
a  complete  disappearance  of  the  itching.  Frequently  the  relief  is 
permanent,  sometimes  a  return  in  a  few  weeks  is  experienced  when  a 
shorter  course  of  exposures  again  becomes  effective. 

When  apparent  causes  have  received  due  attention,  and  the  dis- 
ease has  resisted  all  treatment,  operative  interference  may  become 
necessary. 

Sanger's  conclusions  on  this  point  are  based  upon  experience,  and 
deserve  attention.    He  says: 

1.  The  partial  or  total  extirpation  of  the  vulva  is  a  legitimate  opera- 
tion which  should  be  performed  in  chronic,  otherwise  incurable  pruritus 
vulvce.    He  calls  the  disease  vuhitus  pruriginosa. 

2.  The  removal  of  the  glans  clitoridis,  especially  in  elderly  women, 
in  whom  the  nerve  terminations  have  usually  lost  their  specific  sensi- 
bility by  reason  of  the  disease,  is  permissible. 

.3.  In  younger  persons,  if  the  irritation  is  circumscribed,  one  may 
try  to  give  relief  by  a  partial  operation  without  removal  of  the  clitoris. 
In  elderly  women,  and  sometimes  even  in  younger  women,  when  the 
disorder  is  extensive,  the  whole  vulva  should  be  extirpated  and  the 
parts  repaired  by  a  corresponding  plastic  operation.  See  Surgical 
Treatment  of  Kraurosis  Vulvae. 

HYPEUffiSTHESIA   OF   THE   VULVA 

Thomas  has  described,  under  this  name,  a  rare  disorder  of  the  \'iilva 
which  occurs  in  hysterical  and  despondent  women  at  or  near  the  meno- 
pause. It  consists  of  an  excessive  sensibility  of  the  nerves  supplying 
the  mucous  membrane  of  some  part  or  all  of  the  vulva.  The  slightest 
friction  excites  intolerable  pain  and  nervousness;  even  a  current  of 
cold  air  produces  discomfort,  and  the  least  pressure  is  intolerable. 
Sexual  intercourse  is  often  impossible.  The  disease  sometimes  is  asso- 
ciated with  vulvitis  or  a  painful  urethral  caruncle;  in  other  cases  no 
tangible  or  visible  cause  can  be  found.  It  differs  from  pruritus  by  the 
absence  of  itching,  and  from  vaginismus  in  not  causing  spasmodic 
contraction  of  the  vagina. 


VAGINISMUS  205 


Treatment  of  Hyperaesthesia  of  the  Vulvae 

The  treatment  is  unsatisfactory.  Botli  tiie  c-c^nijjlele  destruction 
of  the  mucous  membrane  of  the  sensitive  area  with  caustics  and 
excision  lune  failed  to  <;ive  relief.  Sexual  intercourse  should  he  j)ro- 
hihited  and  the  patient  placed  in  hygienic  surroundings  with  cheerful 
company.  The  general  treatment  is  by  tonics,  sea-bathing  or  warm- 
water  bathing,  and  massage.  Local  lesions,  if  present,  are  treated 
according  to  their  special  mdications. 


VAGINISMUS 

Like  pruritus  vulva?,  vaginismus  is  not  a  disease,  but  a  nervous 
symptom  due  in  some  cases  to  appreciable  and  in  others  to  unknown 
causes.  It  is  characterized  by  spasmodic  contractions  of  the  muscles 
surrounding  the  vulva  and  lower  portion  of  the  vagina.  The  condition 
is  analogous  to  laryngismus.  The  spasms  occur  upon  attempteri  coitus 
or  upon  the  attempt  to  make  a  digital  or  speculum  examination.  The 
writer  has  observed  one  strongly  neurotic  case  in  which  the  woman 
declared  that  the  spasm  occurred  violently  whenever  coitus  was  at- 
tempted, but  not  the  slightest  objection  was  made  to  digital  or  speculum' 
examination. 

Etiology  and  Clinical  Course  of  Vaginismus 

The  condition  is  confined  mostly  to  young  neurotic,  hysterical 
women.  The  palpable  or  visible  lesion  is  usually  in  the  form  of  an 
irritable  hymen  or  an  irritable  caruncle  of  the  meatus  urinarius.  If 
the  hymen  has  been  ruptured,  the  irritation  will  be  in  the  remains 
of  it — the  carunculfe  myrtiformes.  These  caruncles  and  the  urethral 
caruncle  in  some  cases  contain  a  superabundance  of  excessively  sensitive 
nerve-filaments.  They,  in  fact,  may  resemble  neuromata.  In  other 
cases  the  sensitive  caruncles  are  absent,  and  the  vaginismus  is  charac- 
terized only  by  an  excessively  sensitive  vaginal  outlet,  which  may  or 
may  not  be  the  seat  of  inflammation  or  erosion.  Repeated  attempts 
at  coitus  against  an  unyielding  intact  hymen  may  give  rise  to  Atilvitis 
and  extreme  tenderness — a  condition  which  should  not  be  confounded 
with  vaginismus. 

There  may  be  no  appreciable  cause  of  the  disorder  save  a  progres- 
sively increasing  nervous  apprehension  on  the  part  of  the  wife;  each 
attempt  gives  rise  to  greater  nervous  excitement  until  the  pain  and  fear 
of  coitus  and  the  extreme  spasmodic  contraction  of  the  levator  ani 
and  neighboring  muscles  which  form  the  sphincter  vaginse  preclude  the 
possibility  of  a  successful  effort.  Thomas  has  given  to  this  distressing 
symptom  the  name  ''dyspareunia."  "Penis  captivtis"  has  been  known 
to  result  from  an  otherwise  normal  coitus. 


206      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 


Treatment  of  Vaginismus 

Any  discoverable  local  cause  should  be  removed.  A  vulvar  tampon 
of  gauze  saturated  with  a  4  per  cent,  solution  of  cocaine,  kept  in 
place  ten  minutes  before  the  attempt,  may  lead  to  successful  coitus, 
therefore  to  uterogestation  and  parturition,  which  in  most  cases,  and 
though  not  in  all,  effects  a  cure. 

Vulvar  inflammation  and  erosion  require  the  treatment  described 
under  Vulvovaginitis.  Excision  of  the  irritable  caruncles  and  gradual 
or  forcible  dilatation  of  the  vagina  have  in  many  cases  given  relief. 
The  mere  division  of  a  rigid  or  imperforate  hymen  may  be  sufficient 
to  remove  the  obstacle.  Gradual  dilatation  is  made  by  the  introduction 
of  graduated  rectal  bougies,  to  be  worn  an  hour  or  more  daily.  Forcible 
dilatation  requires  ether,  and  should  be  followed  by  the  continued 
wearing  of  a  Sims  vaginal  plug.  Meantime  the  patient  remains  in  bed 
until  the  divulsed  vaginal  walls  have  healed.  The  plug  should  be 
removed  only  during  urination,  defecation,  and  the  giving  of  the  vaginal 
douche;  after  healing,  it  may  be  introduced  daily  by  the  patient  in 
order  to  retain  the  effects  of  the  divulsion.  In  obstinate  cases  divulsion 
will  be  inadequate.  It  is  sometimes  necessary  to  incise  deeply  at  several 
points  or  to  make  two  quite  deep  lateral  incisions  on  either  side  near 
the  posterior  vulvar  commissure.  These  incisions  should  divide  com- 
pletely the  underlying  muscles  and  their  fascia;  they  may  be  closed 
by  lines  of  union  running  at  right  angles  to  the  directions  in  which  the 
incisions  were  made,  or  until  healing  is  established  they  may  be  kept 
open,  as  already  described,  by  means  of  the  vaginal  plug.  See  index 
for  Sims'  vaginal  plug. 


CHAPTER  XIII 
]\lKTRrnS— IXFLAMISIATIOX   OF  THE   ITEIirS 

General   Considera  ions 

This  chapter  should  be  read  in  connection  with  Chapter  X.,  on 
the  (Tcneral  Principles  of  Infection  and  Inflammation  of  the  Pelvic 
Organs;  and  Chapters  \1\.  to  XML,  which  treat  of  metritis  as  it 
affects  the  ^'a^ious  parts  of  the  uterus. 

Inflammation,  broadly  defined  as  the  reaction  which  living  tissue 
exhibits  to  morbid  irritation,  may  include  a  wide  variety  of  lesions. 
These  lesions,  as  related  to  the  uterus,  have  variously  and  sometimes 
vaguely  been  designated  as  chronic  metritis,  subacute  metritis,  sub- 
inflammatory  states,  irritative  states,  and  congestive  states. 

Anatomy. — Before  entering  upon  the  study  of  metritis,  which  is 
the  study  of  the  anatomy  and  physiology  of  the  uterus  as  modified 
by  inflammation,  the  following  suggestion  of  such  parts  of  the  anatomy 
and  physiology  as  will  aid  in  a  description  of  these  inflammatory  pro- 
cesses will  be  useful. 

The  interior  of  the  uterus  is  divided  into  two  cavities,  the  cavity 
of  the  corpus  and  the  cavity  of  the  cervix.  The  former  is  protected 
somewhat  from  infection  from  abo\'e  by  the  two  muscular  constrictions 
which  divide  it  from  the  Fallopian  tubes;  from  below  by  a  similar 
arrangement  at  the  internal  os.  The  cavity  of  the  cervix  is  protected 
in  like  manner  from  infection  from  above  by  the  internal  os;  from 
below  by  the  external  os. 

Corporeal  Portion  is  made  up  of  three  layers;  the  mucous  layer,  called 
the  endometrium;  the  muscular  layer,  called  the  myometrium,  con- 
sisting of  three  coats;  and  the  serous  or  peritoneal  layer,  sometimes 
called  the  perimetrium. 

The  Endometrium  is  composed  of  lymphatics,  blood-vessels,  nerves, 
glands,  connective-tissue  cells,  and  a  single  layer  of  ciliated  columnar 
epithelium.  This  epithelium  also  lines  the  uterine  glands  and  is  con- 
tinued through  the  Fallopian  tubes.  The  same  variety  of  epithelium, 
modified,  also  lines  the  cavity  of  the  cervix  uteri.  Pa\'ement  epithelium 
beginning  at  the  external  os,  covers  the  external  vaginal  portion  of  the 
cervix. 

The  Glands  of  the  Corpus  Uteri  are  tubular,  narrow,  branching 
depressions.  They  dip  down  into  and  through  the  endometrium  and 
penetrate  to  the  muscularis.  These  tubular  glands,  penetrating  every- 
w^here  throughout  the  endometrium,  make  up  a  very  large  part  of  its 
volume.  They  all  open  into  the  uterine  cavity,  sometimes  two  by  a 
single  orifice. 

(207) 


208      INFECTIONS,    INFLAMMATIONS,   AND   ALLIED   DISORDERS 

The  corporeal  endometrium  is  bound  firmly  to  the  inner  coat  of 
the  muscularis  by  connective  tissue  which  is  continuous  with  that  of 
the  myometrium. 

Lym'ph-  and  Blood-vessels  and  Nerms. — The  lymph-spaces  and  lymph- 
vessels  of  the  uterus  are  abundant  in  the  endometrium,  in  the  muscular 
strata,  and  in  the  serosa.  Converging,  they  pass  by  large  channels 
outward  through  the  broad  ligaments.  Figure  86,  and  the  Frontis- 
piece, Plate  I.  The  uterus  is  supplied  richly  with  nerves,  both  spinal 
and  sympathetic.  The  arteries  and  veins  are  illustrated  in  the  Frontis- 
piece and  in  the  chapter  on  IMyomata,  under  INIyomectomy. 

Figure  8G 


Long  section  of  the  uterus  and  adjacent  parts — rectum,  vagina,  and  bladder.  The  layers  of  the 
uterine  wall  are  indicated;  they  are  the  mucous  layer  or  endometrium,  the  three  muscular  layers 
comprising  the  myometrium,  and  the  serous  or  peritoneal  laj^er,  known  as  the  perimetrium. 


The  Cervical  Portion  differs  from  that  of  the  corpus  uteri  in  the  fol- 
lowing particulars.  Its  mucous  surface  has  a  peculiar  arbor  vitse  appear- 
ance, as  shown  in  Figures  88  and  89.  "  The  upper  two-thirds  of  the 
intracervical  mucosa,  like  the  corporeal,  is  lined  with  a  single  layer  of 
ciliated  columnar  epithelial  cells,  which,  similar  to  those  of  the  corpus, 
and  modified  to  the  shape  of  a  cup,  pass  without  cilia  into  the  cervical 


METIiiriS—IM'LAMMM'loS   OF   Till-:   UTERUS 


209 


.uhiiids;  tlu'  ('i)itlR'liiiiii  ill  (lir  lower  third  <,Ta(liialiy  cliaii^^cs  to  s(|iiainous 
epitlicliuin,  and  at  the  os  externum  is  continuous  with  tiie  sciuanious 
epithelium    of    the    vagina.      The    connective-tissue    cells    are    closer 


FuiruK  s 


Lymphatics  of  the  uterus. 


Figure 


Figure  89 


.  ^■.^'■-'  '^f/  V'\ 


• 


-1 


Figure  88. — Arbor  ^^t8e  arrangement  of  cervical  mucosa.     Natural  size. 
Figure  89. — Arbor  vitae  appearance  of  cer\ncal  mucosa.     Magnified. 

together  n  the  cervical  than  in  the  corporeal  mucosa,  but  the  cer\ical 
mucosa,  more  dense  than  the  corporeal,  is  bound  less  firmly  to  the 
muscularis  by  looser  connective  tissue. 
14 


210     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

An  important  function  of  the  cervix  is  that  of  a  sphincter  to  separate 
the  corpus  uteri  from  the  vagina.  The  normal  secretion  of  the  uterine 
glands  is  alkaline,  that  of  the  corpus  clear  and  watery,  that  of  the 
cervix  clear  and  viscid.  A  yellow  secretion  is  evidence  of  disease. 
The  minute  anatomy  of  the  uterine  mucosa  will  be  described  in 
Chapter  XVI.,  on  Chronic  Endometritis. 

The  essential  function  of  the  corporeal  mucosa  is  the  formation  of 
the  decidua  and  the  nourishing  of  the  embryo.  The  connective-tissue 
cells  produce  the  cells  of  the  decidua  of  pregnancy;  this,  with  the 
progress  of  uterogestation,  matures,  becomes  overripe,  degenerates, 
and,  being  of  no  further  use,  is  cast  off  at  term. 

The  most  significant  factor  in  metritis  is  the  endometrium.  It 
exhibits  in  the  developmental  and  atrophic  changes  of  puberty  and 
the  menopause,  in  the  vascular  changes  of  the  menstrual  ebb  and  flow, 
widely  and  constantly  varying  states.  Inflammation  of  the  uterus  may 
occur  during  infancy,  before  the  endometrium  has  matured;  during 
puberty,  when  it  is  maturing;  during  maturity,  when  it  has  reached 
its  full  physiological  significance;  during  the  menopause,  when  it  is 
undergoing  degeneration;  or  during  senility,  when  in  the  physiological 
sense  it  has  disappeared  forever.  The  occurrence  of  metritis  under 
such  diverse  conditions  partly  explains  the  wide  and  variable  range  of 
its  phenomena  and  the  difficulty  of  description,  and  partly  accounts 
for  the  confusion  of  classification  and  conflicting  nomenclature  which 
runs  through  the  literature. 

Classification  of  Metritis 

When  infection  reaches  the  uterus,  it  usuall}'  attacks  first  the  mucosa, 
and  then  may  extend  to  the  m}'ometrium  and  perimetrium.  Metritis 
is  therefore  a  combination  of  endometritis,  myometritis,  and  peri- 
metritis. The  storm-centre  of  the  infection  is  usually  the  endometrium 
and  the  essential  lesion  endometritis.  It  is  impossible  to  draw  definite 
lines  of  division  between  these  three  forms  of  metritis.  The  terms 
endometritis,  myometritis,  and  'perimetritis  ivill  be  used  therefore  not  to 
describe  separate  and  distinct  lesions,  but  rather  to  identify  the  morbid 
changes  that  may  occur  in  definite  parts  of  an  infected  uterus.  The 
attempts  to  classify  inflammation  of  the  various  parts  of  the  uterus  as 
separate  and  distinct  lesions,  or,  for  that  matter,  to  draw  a  definite 
line  between  the  acute  and  chronic  stages,  although  diagrammatically 
attractive,  are  clinically  impossible. 

Such  words  as  gonorrhoeal,  parenchymatous,  hemorrhagic,  purulent, 
and  catarrhal  are  convenient  for  purposes  of  description.  The  division 
endometritis,  for  example,  may  be  used  to  describe  not  a  distinct  lesion 
independent  of  the  rest  of  the  uterus,  but  rather  the  most  significant 
factor  of  the  inflammatory  condition  of  uterine  infection.  In  this  way 
we  shall  not  lose  sight  of  the  clinical  relations  between  the  various 
forms  and  phases  of  metritis. 


CHAPTKK    XIV 
ACUTE  METRITIS 

Etiology   of  Acute   Metritis 

TiiF,  tj;ciier;il  suhjcct  of  ctioloijy  has  \)vv\\  outlined  in  Chapter  X.,  on 
CeiuTai  Principles  of  liiHanimations. 

Predisposing  Causes. — Those  influenees  that  induee  pelvie  congestion 
are  faxoring  eonchtions  for  metritis;  they  are: 

1.  Menstrual  congestion. 

2.  Suppression  of  the  menses. 
o.  Displacements. 

4.  Constriction  and  consequent  obstruction  in  the  uterine  canal. 

5.  The  improper  use  of  pessaries. 
G.  Parturition  and  abortion. 

7.  Traumatisms. 

8.  Excessive  coitus. 

Formerly  these  conditions  and  others  like  them  were  supposed  to 
be  the  essential  causes.  Xow  it  is  known  that  they  contribute  to  the 
production  of  metritis  as  predisposing  causes  by  preparing  the  field 
for  infection. 

Exciting  Causes. — Bacteria  and  their  products  in  substantially  every 
case  are  the  exciting  causes.  These  bacteria  have  been  discussed 
generally  in  the  General  Principles  of  Inflammation,  Chapter  X.,  and 
particularly  in  the  Etiology  of  Vulvovaginitis.  They  usually  invade 
the  cavity  of  the  cervix  uteri  from  below,  intrench  themselves  in  the 
cervical  glands,  and  thence  may  be  distributed  directly  by  continuity 
or  contiguity  of  tissue  to  the  endometrium,  myometrium,  perimetrium, 
parametrium,  Fallopian  tubes  and  ovaries,  and  may  invade  the  pelvic 
or  general  abdominal  cavity.  Bacteria  also  may  pass  directly  by  the 
lymphatic  or  venous  circulation  from  the  cervix,  vagina,  rectum,  or 
bladder  to  the  ovaries  and  peritoneum.  From  these  organs  they  may 
descend  by  continuity  of  the  mucosa  through  the  tubes  to  the  endo- 
metrium. 

The  cavities  of  the  cervLx  and  corpus  uteri,  especially  the  latter, 
are  normally  free  from  pathogenic  bacteria;  bacteria,  however,  may 
easily  find  access  to  these  parts,  and  will  then  be  active  or  inactive, 
according  to  their  virulence  or  the  degree  of  resistance  which  the  tissues 
exhibit  to  their  presence.  The  corporeal  and  cervical  mucosa,  pene- 
trated throughout  with  a  great  abundance  of  tubular  glands,  are  adapted 
especially  to  incubate  and  distribute  bacteria.  This  accounts  for  the 
tendency  of  metric  and  perimetric  infection  to  become  chronic. 

The  (jonococcus  of  Xris-'^er,  since  it  has  great  power  to  penetrate 
the  glandular  elements  and  to  intrench  itself  therein,  is  one  of  the 

(211) 


212     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

most  frequent  and  destructive  causes  of  metritis.  The  staphylococci 
of  suppuration  are  found  commonly  also  in  suppurative  endometritis 
The  streptococcus  pyogenes,  very  infectious  and  fatal,  produces  one  of 
the  graver  forms  of  puerperal  and  traumatic  pelvic  infection.  The 
great  danger  of  this  germ  is  in  the  fact  that  it  does  not  strongly  attract 
leucocytes,  and  therefore  does  not  excite  much  defensive  action.  The 
diphtheria  and  tubercle  bacilli,  bacillus  coli  communis,  and  other  bacteria 
may  also  be  the  exciting  causes  of  metritis. 

During  the  three  or  four  days  after  parturition  and  just  before 
menstruation  the  physiological  congestion  of  the  uterus  renders  it 
most  susceptible  to  infection.  The  cervical  portion  at  all  times  is 
subject  to  invasion  by  pathogenic  germs;  such  germs  often  are  intro- 
duced by  the  physician's  finger,  or  upon  septic  instruments  of  which 
the  unclean  uterine  sound  is  a  striking  example.  The  infectious 
material  may  be  inactive  unless  the  soil  is  prepared  to  receive  and 
develop  it;  but  when  the  traumatisms  of  abortion  and  parturition,  of 
accident  and  of  surgery,  have  opened  wide  the  door  for  bacterial  inva- 
sion, infection  will  be  the  natural  result. 


Pathology  of  Acute  Metritis 

The  lymph-channels  and  blood-vessels  bring  into  direct  and  close 
communication  with  one  another  the  endometrium,  myometrium,  para- 
metric cellular  tissue.  Fallopian  tubes,  ovaries,  and  peritoneum.  The 
uterine  mucosa  thus  becomes  both  the  starting-point  and  the  distrib- 
uting-point of  infection.  The  infected  endometrium  may  abundantly 
pour  its  toxic  products  through  the  lymph-  and  blood-streams,  with 
resultant  lymphangitis,  phlebitis,  cellulitis,  salpingitis,  ovaritis,  and 
peritonitis. 

The  close  physiological  and  anatomical  relations  of  the  lymph- 
stream  to  the  endometrium  and  uterine  peritoneum  partially  explain 
the  swift  and  terrible  march  of  traumatic  and  puerperal  infections  to  a 
destructive  or  fatal  result.  The  bacteria,  usually  streptococci  or  other 
pus  cocci  and  their  products,  are  taken  up  and  widely  distributed  by 
the  lymphatics  or  veins.  They  may  be  carried  through  the  vessels  with- 
out infecting  them,  or  may  infect  them  and  produce  lymphangitis, 
lymphadenitis,  or  phlebitis.  The  inflammation  may  be  so  intense  as  to 
destroy  the  vessels,  or  resolution  may  bring  about  complete  recovery. 
Inflammation  in  the  lymphatics  or  veins  may  result  in  lymph  thrombosis 
or  venous  thrombosis.  This  is  nature's  way  of  limiting  the  spread  of 
the  infection.  When  recovery  takes  place,  the  lymph-  or  blood-stream 
is  reestablished  around  the  thrombosed  parts  of  these  vessels  by  col- 
lateral circulation.  Perilymphangitis  and  periphlebitis  may  occur  in 
the  cellular  tissue  around  the  thrombosed  lymphatics  and  veins.  This 
process  when  it  takes  place  in  the  parametria  is  pelvic  cellulitis,  a  dis- 
ease almost  forgotten  in  these  days  of  tubal  and  ovarian  pathology. 
See  Pelvic  Cellulitis. 


ACITK  MKTiaris  213 

The  Jiiiatoiniciil  (•h;inp;es  may  be  summarized  as  follows: 

rtcTUs  eiilar<;('(l,  rcfiular  in  oiitiliic,  and  of  doughy  or  soft  con- 
sistence. 

Congestion  extreme;  there  may  he  extravasation  of  blood  in  the 
muscularis. 

Endometrium  and  perimetrium  deeply  reddened  in  circumscribed 
areas  throughout. 

Small-cell  infiltration  of  interglandular  and  intermuscular  connective 
tissue. 

PvUgorgement  of  lymph-vessels  and  engorgement  and  excessive  secre- 
tion from  the  uterine  glands. 

Cloudy  swelling  and  desquamation  of  epithelium  lining  the  endo- 
metrium and  glands. 

Abscesses  rarely  develop  in  the  myometrium  except  in  connection 
with  myomata.  Inflammation  of  the  mucosa  may  be  catarrhal,  sup- 
purative, ulcerative,  hemorrhagic,  or  all  combined. 

The  milder  cases,  chiefly  characterized  by  engorgement,  increased 
secretion,  and  pain,  may  subside  in  a  few  days,  and  the  uterus  either 
may  become  normal  or  lapse  into  a  state  of  chronic  metritis.  In  the 
more  severe  forms  the  disease  may  run  a  destructive  course  to  the 
death  or  permanent  disability  of  the  patient,  and  will  in  extent  vary 
with  the  virulence  of  the  exciting  cause  and  the  resistance  of  the 
inflamed  structures. 

A  grave  form  of  acute  disease  has  been  described  under  the  name 
dissecting  metritis.  The  infection  is  usually  puerperal,  but  is  some- 
times a  sequel  of  non-puerperal  diphtheria.  It  may  be  associated  with 
gangrene  of  the  vulva,  and  may  occur  after  scarlet  fever,  typhoid  fever, 
or  cholera.  "In  puerperal  cases,"  says  Garrigues,  "the  diphtheritic 
infiltration  may  extend  from  the  endometrium  to  the  neighborhood  of 
the  peritoneum,  cutting  off  a  large  part  of  the  muscular  layer,  which 
after  weeks  or  months  will  be  expelled  as  a  pear-shaped  body."  Dis- 
secting metritis  may  be  connected  with  similar  disease  of  the  vulva  and 
vagina. 

The  ultimate  possible  changes  which  may  follow  acute  metritis  in 
the  uterine  glands,  uterine  connective  tissue  and  muscularis,  and  in  the 
peritoneal  covering  of  the  uterus,  are  discussed  elsewhere.  See  Chronic 
Endometritis,  Chronic  Metritis,  and  Peritonitis. 

Symptomatology  and  Diagnosis  of  Acute  Metritis 

The  symptoms  of  acute  metritis  depend  upon  the  extent  and  gravity 
of  the  disease,  and  therefore  may  vary  within  wdde  limits  from  those 
of  a  mild  infection  to  those  of  the  greatest  virulence.  An  apparently 
mild  metritis  may,  however,  result  in  the  most  destructive  pelvic 
infection  with  all  the  results  of  grave  peritonitis. 

The  onset  is  acute,  with  variable  high  temperature;  rapid  pulse; 
pain  more  or  less  intense,  and  lancinating  to  the  back  and  thighs;  rectal 
and  vesical  tenesmus,  and  generally  hemorrhagic  mucous,  or  purulent 


214      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

secretion  from  the  inflamed  glands,  which  in  gonorrha'a  is  more  decidedly 
purulent.  The  engorged  vessels  may  be  relieved  by  menorrhagia. 
When  the  inflamed  uterus  contracts  to  expel  its  abundant  secretions 
the  agony  is  that  of  exaggerated  labor-pains.  Bearing-down  and  heat 
in  the  pelvis  are  often  excessive.  When  the  disease  has  extended  to  the 
Fallopian  tubes,  pelvic  connective  tissue,  ovaries,  and  especially  when 
it  invades  the  peritoneum,  there  may  be  grave,  even  fatal  toxaemia 
with  anxious  facies,  increased  vomiting,  obstipation,  and  tympanites. 

The  diagnosis  is  based  upon  the  pathology  and  symptoms  just  de- 
scribed, which,  if  present,  will  give  rise  to  the  following  physical  signs: 

Tenderness  on  pressure  over  the  hypogastrium  and  in  the  vaginal 
fornix. 

Abdominal  muscles  tense. 

Vagina  dry  and  hot  to  the  touch. 

Pathological  secretions  from  associated  endometritis. 

Uterus  enlarged,  softened,  and  tender. 

Examination  is  often  so  painful  as  to  be  impracticable  without 
anaesthesia;  the  os  uteri  is  usually  patulous,  and  often  surrounded  by 
erosion.  The  vagina  is  hot,  and  the  arteries  strongly  pulsating.  The 
urgent  necessity  is  to  watch  for  tubal  and  peritoneal  extension.  See 
Diagnosis  of  Salpingitis  and  Pelvic  Peritonitis.  The  mere  recogni- 
tion of  acute  metritis  is  wholly  inadequate.  Unless  the  state  of  the 
uterine  appendages  and  parametria  is  made  out  accurately,  thera- 
peutic indications  of  the  greatest  urgency  may  be  overlooked;  it  may 
be  necessary  therefore  to  make  one  or  more  examinations  under  anaes- 
thesia. In  all  acute  inflammations  of  the  genitals  intra-uterine  instru- 
mentation is  contraindicated. 

Prognosis  of  Acute  Metritis 

The  prognosis  of  acute  metritis  is  always  disquieting,  often  grave. 
The  disease  may  terminate  in  resolution  or  in  chronic  metritis.  Ex- 
tension to  the  peritoneum  involves  immediate  danger  to  life  and  remote 
danger  to  health.  The  relative  virulence  of  different  bacteria  has  been 
mentioned  in  the  paragraphs  on  Etiology.  Puerperal  metritis  is  most 
likely  to  spread  with  the  lymph-stream,  is  especially  grave  when  due 
to  such  virulent  bacteria  as  the  streptococcus  pyogenes,  and  even 
when  early  recognized  and  promptly  treated  by  radical  surgery  is  apt 
to  result  fatally,  for  the  toxins  are  especially  deficient  in  their  power 
to  attract  leucocytes — that  is,  to  build  up  a  limiting  w^all  around  the 
infected  centre  and  thereby  to  protect  the  general  system  against 
invasion.  For  this  reason  the  infection  may  reach  the  uterus  in  an 
hour;  in  two  or  three  hours  more  it  may  have  passed  far  beyond  the 
uterus,  where  surgery  cannot  reach,  much  less  remove  it. 

Treatment  of  Acute  Metritis 

Bacteriological  research  has  opened  the  w^ay  for  an  etiological  classi- 
fication that  should  furnish  a  safe  and  definite  guide  to  the  therapeutic 


ACITE   METRITIS  215 

iii(li(;itit»ii.  Scnmi  ami  xacciiif  therapy  alrcadx'  lia\c  cstahlislicd 
tlu'insi-hcs  on  firm  sciciitiMc  ^rdiind  and  ij,i\c  nnicli  promise  of  practical 
results. 

The  treatment  is  prophylactic,  genera!,  and  snruical.  See  Trcatinent 
on  Se|)>i->  in  ("hapter  \  1 11. 

Prophylaxis  includes  the  axoidance  or  remo\al  of  the  pre<lisjjosin^' 
and  excitiu';  causes.  Reference  to  the  etioloj^y  will  su^jgest  the  appro- 
priate indications.  Susceptibility  is  jireater  durinf;  the  puerperal 
state,  parturitit)!!,  abortion,  and  menstruation.  Extra  care,  therefore, 
at  such  times  is  essential.  Especially  for})i(l  undue  exposure  of  all 
kinds.  Avoid  the  bacterial  exciting  causes  by  asepsis.  The  minor 
gynecological  and  obstetrical  examinations  and  manipulations  without 
asepsis  are  dangerous.  Above  all,  one  should  use  every  means  to  pre- 
vent the  spread  of  a  vulvovaginitis,  especially  if  it  be  gonorrhcjeal,  to 
the  uterus.     See  Treatment  of  Vulvovaginitis. 

General  Treatment  may  be  outlined  as  follows:  Eowler's  position, 
rest  in  bed,  liquid  diet,  mercurial  purge,  followed  by  salines,  control 
of  temperature  by  sponging  and  other  hydrotherapeutic  measures; 
ice-bags  freely  applied  to  the  lower  abdomen;  anodynes,  including 
soporifics.  Severe  pain  may  be  relieved  by  suppositories  of  extract 
of  opium,  one  grain,  and  extract  of  belladonna,  one-sixth  grain.  Water 
should  be  taken  in  large  quantities.  If  nausea  prevents  the  giving 
of  it  by  mouth  let  normal  salt  solution  be  infused  into  the  rectum  by 
the  drop  method  as  described  in  Chapter  VIII.  Ergot  and  hydrastin 
either  by  the  mouth  or  by  suppository  are  recognized  as  exerting  a 
tonic  and  therefore  beneficial  influence  on  the  uterine  muscularis  and 
circulation.  The  action  of  these  two  drugs  on  the  uterus  may  contract 
the  organ  so  as  to  limit  infection  of  the  endometrial  surfaces  to  lessen 
absorption  and  cause  expulsion  of  pathological  secretions  and  retained 
products  of  conception. 

Bacteriological  research  has  opened  the  way  to  an  etiological  classi- 
fication that  may  furnish  a  safe  and  definite  guide  to  a  most  important 
therapeutic  indication.  Serum  and  vaccine  therapy  already  have 
established  themselves  on  firm  ground.  It  is  confidently  hoped  that 
in  the  near  future  vaccine  therapy  will  become  a  more  exact  and  there- 
fore more  dependable  science.  Autogenous  vaccine,  that  is,  vaccine 
derived  from  the  bacteria  of  the  patient,  is  preferable.  Since,  however, 
immediate  treatment  of  acute  metritis  may^  be  imperative,  commercial 
vaccine  may  be  used  for  the  time  being,  a  smear  having  been  made 
to  determine  the  variety  of  the  organism,  until  the  autogenous  vaccine 
can  be  prepared. 

Surgical  Treatment. — The  milder  self-limited  infections  which  ha^'e 
no  grave  systemic  or  local  manifestations  may  be  dismissed  with 
palliative  or  expectant  treatment.  In  grave  infections  it  may  be 
extremely  difficult  or  impossible  to  choose  wisely  between  the  danger 
of  the  disease  and  the  extra  peril  of  surgical  interference;  hence,  even 
in  serious  cases,  the  expectant  course  may  be  the  part  of  wisdom. 
When  the  systemic  condition  is  urgent  and  the  nervous  system  indi- 


216      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

cates  profound  toxsemia  the  disease  under  any  treatment  will  in  a 
large  proportion  of  cases  terminate  fatally.  A  number  of  practical  and 
momentous  questions  at  once  arise: 

Question  1.  Is  there  simple  absorption  into  the  circulation  from 
some  focus  of  decomposition  in  the  uterus?  Is  the  toxaemia  due  to 
the  products  of  a  decomposing  foreign  body,  such  as  a  blood-clot,  a 
fragment  of  placenta,  retained  membrane,  or  pent-up  lochia?  In 
other  words,  is  it  due  to  the  absorbed  products  of  putrefactive  bacteria  ? 
To  put  the  question  in  more  concise  form,  Is  it  saprsemia? 

Question  2.  Is  the  uterine  mucosa  the  seat  of  an  infection,  and 
as  such  is  it  the  distributing-point  of  bacteria  which  may  spread  and 
infect  the  uterine  appendages  and  peritoneum?  If  the  bacterial  in- 
vasion has  extended  beyond  the  uterus,  to  what  extent  are  the  uterine 
appendages  and  peritoneum  invaded?  Is  the  systemic  disturbance 
such  as  to  suggest  that  bacteria  and  their  products  are  very  liable 
to  enter  the  general  circulation  in  quantities  sufficient  to  give  rise  to 
pronounced  septicaemia? 

Question  3.  Have  pus  emboli  been  carried  through  the  circulation 
from  one  focus  of  suppuration  to  set  up  other  foci  in  different  parts  of 
the  body,  and  thereby  produce  metastatic  abscesses?  To  put  the 
question  in  another  form.  Is  there  pyaemia? 

If  the  answer  to  the  first  question  be  in  the  affirmative,  that  is, 
if  there  is  in  the  uterus  a  putrefying  mass,  many  operators  would  re- 
move it,  wash  out  the  endometrium,  and  establish  drainage.  The 
offending  substance  may  be  removed  with  the  finger,  the  placental 
forceps,  the  dull  curette,  or,  if  the  uterine  canal  be  open,  may  be  wiped 
out  with  a  gauze  swab  attached  to  a  long  forceps.  Sapraemic  cases 
recover  seemingly  as  the  result  of  this  kind  of  surgical  interference. 
Experience,  however,  has  shown  that  they  recover  more  normally  and 
with  fewer  exceptions  under  the  general  treatment  already  outlined, 
such  as  Fowler's  position,  rest,  diet,  ice-bags,  and  ergot.  Surgical 
interference  therefore  is  objectionable,  but  it  is  rendered  much  more 
so  by  the  difficulty  of  differentiating  sapraemia  from  septicaemia,  and 
by  the  fact  that  for  septicaemic  cases  it  always  will  result  in  appalling 
mortality;  it  therefore,  generally  speaking,  should  be  confined  to  those 
cases  of  metritis  in  which  there  is  in  the  uterus  a  foreign  body,  such, 
for  example,  as  the  secundines  of  an  abortion  which  is  producing  hemor- 
rhage, and  which  should  be  removed  on  that  indication  alone. 

If  the  answers  to  the  second  and  third  queries  are  in  the  affirma- 
tive, it  becomes  essential  to  decide  whether  the  infection  has  spread  so 
far  beyond  the  uterus  as  to  make  the  metritis  relatively  insignificant. 
Clearly,  if  there  are  abscesses,  they  should  be  opened;  if  infection  has 
spread  to  the  other  pelvic  organs,  surgical  treatment  of  the  uterine 
infection  alone  would  be  useless  and  would  add  to  the  danger. 

The  milder  cases,  as  already  stated,  may  safely  be  left  to  palliative 
and  expectant  treatment.  The  graver  infections  unfortunately  have 
in  the  majority  of  cases  passed  beyond  the  range  of  intra-uterine  thera- 
peutics before  the  question  of  operative  interference  is  forced  upon  the 


ACUTE  METRITIS  217 

surgeon.     We  may,  liowever,  be  concerned  with  the  question,  What 

sur<;ical  measures,  it'  any,  are  justifiable  in  the  effort  to  pre\ent  the 
further  spread  of  dangerous  acute  uterine  infection  whicii  still  is 
confined  nearly  or  quite  to  the  uterus? 

Partial,  inefficient  curettage,  which  opens  up  lymphatics  and  veins  to 
fresh  infection,  but  does  not  remove  all  the  infected  mucosa,  will  pre- 
pare the  way  for  further  infection,  which  may  be  more  \irulent  and 
more  sweeping  than  the  first;  as  tersely  stated  by  de  Lee,  such  a  pro- 
cedure is  like  raking  a  patch  of  lawn  after  scattering  seed  over  it — a 
veritable  insemination.  It  is  evident,  therefore,  that  curettage,  if  in- 
dicated at  all,  should  be  thorough;  should,  indeed,  stop  at  nothing 
short  of  the  removal  of  the  entire  infected  mucosa.  The  sharp  curette, 
which  generally  has  been  considered  a  more  dangerous  instrument 
than  the  dull  one,  is  then  less  dangerous.  The  operations  reported 
by  Pry  or,  Krug,  and  others,  indeed,  prove  that  the  sharp  curette  in 
careful  hands  is  much  less  dangerous  than  has  been  supposed.  The 
thorough  application  of  it  in  selected  cases  has,  according  to  some 
reports  been  followed  by  prompt  decrease  in  the  toxsemia  and  in  the 
other  grave  symptoms. 

The  writer's  personal  conviction  of  the  value  of  dilatation,  curettage, 
and  drainage  of  the  endometrium  in  acute  infection  is  that  the  measure 
if  used  at  all  should  be  limited  in  its  application.  Let  no  man  be  lured  to 
the  performance  of  this  dangerous  operation  in  an  acute  case  because 
of  the  ease,  safety,  and  efficacy  of  the  similar  procedure  in  chronic 
endometritis. 

Clearly  curettage  is  contraindicated  in  the  numerous  and  grave 
cases  in  which  the  infection  has  passed  to  the  parametria,  not  from 
the  endometrium,  but  by  extra-uterine  lymph-vessels  or  blood-vessels. 
All  admit  the  practical  difficulty,  not  to  say  impossibility,  of  selection 
so  as  to  limit  the  operation  to  those  infections  which  are  really  dangerous 
and  still  confined  to  the  uterus.  It  is,  moreover,  certain  that  the  course 
of  grave  infections  seldom  will  be  arrested  by  the  procedure.  At  the 
same  time  few  will  deny  that  the  operation  repeatedly  has  given  rise 
to  fatal  results.  On  the  other  hand,  expectancy  and  palliation  often 
will  be  rewarded  by  the  subsidence  of  grave  symptoms  and  by  final 
recovery.  There  can  be  for  a  surgeon  no  greater  cause  of  regret  than 
the  fact  that  he  has  exhausted  the  resisting  forces  of  his  patient  by  a 
dangerous  meddlesome  measure  which  itself  may  have  contributed  to 
the  indication  for  a  more  radical  operation,  and  that  while  with  the 
promise  of  such  a  measure  he  has  been  lulling  himself  into  a  sense  of 
false  security,  the  infection  has  gained  such  irresistible  force  that  vaginal 
or  abdominal  incision  and  drainage  or  the  removal  of  the  uterus  together 
with  its  appendages  may  seem  at  once  to  be  indicated  by  the  rapid 
spread  of  the  infective  process;  even  then  the  difficulty  in  a  concrete 
case  of  deciding  w-isely  upon  such  extreme  measures  should  lead  one 
to  hesitate  and  to  reflect  that  the  maximum  safety  may  be  in  watchful 
expectancy,  supplemented  by  the  general  treatment  already  described. 


CHAPTER  XV 
CHRONIC  EXDOCERVICITIS 

The  synonyms  of  endocervicitis  are  cervical  catarrh  and  cervical 
endometritis.  Since  the  endometrium  is  situated  entirely  above  the 
internal  os,  there  is  a  manifest  impropriety  in  using  the  word  endo- 
metritis in  connection  with  the  cervix  uteri. 

In  studying  this  subject  the  reader  should  have  constantly  in  mind 
the  anatomical,  physiological,  and  pathological  unity  of  the  reproductive 
organs.  Infection  seldom  is  confined  to  a  single  part  of  the  uterus;  on 
the  contrary,  it  extends  usually  to  other  parts  and  commonly  involves 
adjacent  organs.  We  are  considering  therefore  nothing  less  than  the 
whole  subject  of  metritis,  but  with  special  reference  to  the  cervical 
mucosa.  The  single  layer  of  columnar  epithelium,  the  underlying 
connective  tissue,  the  lymph-spaces,  the  lymphatics,  the  veins,  the 
arteries,  and  the  nerves  which  make  up  the  intracervical  mucosa, 
are  subject  to  certain  chronic  changes  which  are  known  under  the 
name  chronic  endocervicitis.  Similar  disease  of  the  corporeal  mucosa 
is  called  chronic  endometritis. 

Etiology  of  Chronic  Endocervicitis 

Endocervicitis  is  inflammation  of  the  cervical  mucosa.  The  pre- 
disposing and  the  bacterial  excitng  causes  have  been  pointed  out  in 
Chapter  X. 

The  disease  is  in  some  respects  like,  in  others  unlike,  corporeal 
endometritis.  It  often  occurs  by  extension  from  vulvovaginitis.  It 
rarely  descends  from  the  corpus  uteri.  It  may  have  been  carried  as 
a  primary  infection,  without  intermediate  infection  of  the  vulva  or 
vagina,  direct  to  the  cervical  mucosa. 

Although  normally  free  from  pathogenic  bacteria,  the  cervical  cavity 
is  quite  accessible  to  them.  This  explains  the  greater  tendency  of  the 
cervix  at  all  times,  especially  upon  slight  traumatism,  to  become 
infected.  The  cervical  glands,  well  adapted  to  receive,  retain,  and  dis- 
tribute infection,  easily  become  a  culture-ground  for  bacteria.  Once 
intrenched  in  the  gland  crypts,  the  germs  may  remain  relatively  and 
intermittently  quiescent  for  periods  of  time  and  then  may  develop  new 
cultures  and  spread.  Among  the  more  frequent  predis posing  causes 
of  endocervicitis  are  the  following: 

Puerperal  laceration  of  the  cervix. 

Excessive  coitus. 

Foreign  bodies,  tumors,  polypi. 

Dilatation  and  other  instrimientation  and  treatment. 
(218) 


(11  ROMc  r:\  DocEU  vie  it  is. 


219 


77/r  KxcifiiKj  Cdiiscs  arr  hactcria.  t'sj)i'ciall\   ^oiiorrlm  al.  wliidi  may 
R-acli  the  (rrvix  direct  or  1»('  carried  In-  extension. 


Pathology   of   Chronic   Endocervicitis 

The   swollen   mucosa,   especiall\    if  tlie   cervix   be  lacerated,   takes 
the  direction  of  least  resistance,  and   nia\    })rotrnde  throiij,di  the  os 

Fifu-RE  on 


.4,  mucous  poh-pi  of  the  cen^ix  uteri — follicular  hypertrophy.  One  pol>"pus  has  been  seized  with 
forceps  and  is  being  removed  with  scissors.  B.  small  mucous  polypi  hanging  out  of  the  cer\nx  uteri; 
C,  mucous  poljTji  being  removed  from  the  cer^-ical  canal  with  the  sharp  curette. 


externum.  The  thickened  everted  mucous  membrane  may  give  to 
the  cervix  the  appearance  of  great  enlargement.  The  condition  is 
not  unlike  that  of  the  prolapsed  hemorrhoidal  anus.  The  engorged 
open  cervical  glands  in  great  numbers  pour  out  their  secretion  upon 
the  vulvovaginal  stirface.  The  discharge,  unlike  that  of  endometritis, 
is  thick,  ropy,  viscid,  abundant,  and  gelatinous.  It  may  be  dislodged 
onlv  with  difficultv  from  its  anchorage  in  the  cervical  glands. 


220      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

In  nullipara  the  internal  and  external  ora  are  sometimes  so  con- 
stricted as  to  cause  retention  of  the  cervical  secretions  and  consequent 
dilatation  of  the  cervical  cavity.    See  Figures  97  and  98. 

The  chief  pathological  factors  are  erosion  of  epithelium  and  glandular 
enlargement.  In  this  respect  endocervicitis  offers  a  close  analogy  to 
corporeal  endometritis. 

Erosion  of  the  Cervical  Epithelium. — Erosion  of  the  cervix  is  char- 
acterized by  a  red  or  purple,  livid  color,  is  confined  usually  to  the 
area  immediately  around  the  external  os  uteri,  and  not  infrequently 
extends  over  the  entire  vaginal  portion  of  the  cervix;  it  has  the  appear- 
ance of  ulceration,  and  in  the  older  literature  was  so  called.  The 
affected  area,  at  first  demonstrated  microscopically  by  Ruge  and  Veit, 
is  covered  by  a  layer  of  newly  formed  inflamed  epithelium.  The 
epithelium  is  not  destroyed  as  in  ulceration,  but  simply  is  eroded. 
Two  varieties  of  erosion  of  the  cervix  have  been  described: 

1.  Simple  erosion. 

2.  Papillary  erosion — cock's-comb  granulations. 

1.  Simple  Erosion,  which  answers  to  the  description  given  in  the 
preceding  paragraph,  presents  a  smooth,  uniform,  velvety  surface, 
with  little  or  no  formation  of  new  glands,  and,  although  having  the 
appearance  of  ulceration,  shows,  on  microscopical  examination,  the 
characteristic  non-specific  mucous  patches  covered  by  a  single  layer 
of  newly  formed  epithelium. 

2.  Papillary  Erosion. — This  form  of  erosion,  from  its  livid,  red  color 
and  characteristic  projections,  has  been  called  cock's-comb  granula- 
tion. The  irregularity  of  surface  is  due  (a)  to  newly  formed  glands; 
(6)  to  hyperplasia  of  the  connective  tissue  beneath  the  surface  epithe- 
lium and  the  glands;  (c)  to  elevations  of  the  interglandular  surfaces. 
The  surface,  as  in  simple  erosion,  is  covered  by  a  single  layer  of  col- 
umnar epithelium.  The  papillary  projections  in  gross  appearance 
may  resemble  closely  early  cancer,  but,  unlike  that  growth,  are  non- 
friable  and  have  little  disposition  to  bleed  on  handling.  There  is 
abundant  small  round-cell  infiltration  of  the  underlying  connective 
tissue  and  free  secretion  of  mucus. 

Glandular  Enlargement  occurs  in  two  forms: 

1.  Polypoid  glandular  enlargement — mucous  polypi. 

2.  Cystic  glandular  enlargement — cystic  degeneration — some- 

times called  follicular  erosion,  sometimes  ovula  Nabothi. 
1.  The  Polypoid  Glandular  Enlargement  produces  diminutive  mucous 
polypi,  smaller,  of  different  origin,  and  softer  than  fibrous  polypi.  The 
genesis  of  mucous  polypi  is  as  follows:  The  enlarged  glands  protrude 
upon  the  surface;  their  mouths  become  obliterated;  the  glandular 
tissue  is  oedematous  from  retained  secretions;  the  bases  constrict  and 
the  little  masses  become  polypoid;  they  correspond  to  the  so-called 
adenoids  of  nasal  pathology.  A  similar  development  sometimes  occurs 
in  the  endometrium  as  the  result  of  endometritis.  These  mucous 
polypi,  although  the  result  of  inflammation,  are  classified  as  benign 
adenoma  by  some  pathologists. 


CHRONIC  ENDOCERVICITIS  221 

2.  Cystic  Glandular  Enlargement.  Follicular  Erosion, — \'ery  often 
as  the  result  of  erosion  the  openings  of  the  cer\ical  j^hinds  become 
occluded  by  adhesive  inflammation,  so  that  the  glands  are  distended 
by  their  own  secretions.  This  process,  known  as  cystic  degeneration, 
results  in  the  formation  of  numerous  round  submucous  bodies,  some- 
times called  ovula  Nabothi,  but  more  conmionly  known  as  follicular 
cysts  or  retention-cysts;  they  may  be  present  in  number  from  one  to 
several  hundred;  they  are  hard,  tense,  spheroidal  bodies,  varying  in 
size  from  a  millet-seed  to  that  of  a  pigeon's  egg;  and  on  digital  touch 
are  small  and  feel  like  shot  under  the  skin.  Seen  through  the  speculum, 
they  appear  as  rounded  elevations  of  yellow,  blue,  or  gray  color;  they 
contain  inspissated  mucus,  which  sometimes  is  infected  by  pus  micro- 
organisms, forming  small  circumscribed  abscesses.  These  cysts  when 
small  are  lined  with  the  typical  gland  epithelium  of  the  cervix,  but 
as  they  become  distended  the  epithelium  flattens  and  finally  disappears 
through  pressure  atrophy.  Cystic  degeneration,  according  to  Emmet, 
is  a  cause  of  numerous  reflex  nervous  disturbances;  it  rarely  is  seen 
on  the  nulliparous  cervix,  but  is  a  frequent  result  of  laceration,  and  as 
such  will  be  described  further  in  the  chapter  on  that  subject. 


Symptoms  and  Diagnosis  of  Chronic  Endocervicitis 

Endocervicitis  may  cause  no  characteristic  symptoms.  The  symp- 
toms associated  with  it  may  be  due  to  complications,  and  therefore 
have  little  or  no  diagnostic  value;  among  them  are  disordered  men- 
struation, sterility,  pain  in  the  back,  and  a  sense  of  weight  in  the  pelvis. 

Diagnosis  of  the  Condition  is  simplified  by  the  accessibility  of  the 
diseased  structures,  especially  when  the  inflamed  swollen  mucosa  is 
rolled  out  in  contact  with  the  vagina  and  when  the  erosion  extends  out 
over  the  vaginal  portions;  it  must  depend  upon  the  physical  signs,  upon 
microscopical  examinations  of  tissues,  and  of  the  uterine  secretions. 

Lacerations  and  cystic  glandular  enlargement  are  examined  better 
by  digital  touch  than  by  sight.  Erosions  and  mucous  polypi  are  soft 
and  elusive,  and  therefore  are  seen  better  than  felt. 

Speculum  Examination. — The  speculum,  Sims'  speculum  preferred,  will 
disclose  some  or  all  of  the  following  conditions  if  they  exist  outside 
the  external  os: 

Increa.sed  secretion,  loosely  designated  as  leiicorrhcea. 

Margins  and  scars  of  lacerations. 

Retention-cysts — rounded  yellowish  or  bluish  projections. 

Mucous  polypi,  protruding  from  the  external  os. 

Erosions,  as  described  under  pathology. 

External  os  filled  with  a  plug  of  tenacious  mucus  or  mucopus. 

Ulcerations,  which  are  seen  rarely  except  those  of  malignant,  syphilitic, 
chancroidal,  or  tubercular  origin. 

The  secretion  is  always  abundant,  viscid,  and  usually  clear,  but 
may  be  murky  from  admixture  of  epithelium  and  leucocytes;  it  also 


222      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

may  be  yellow  or  greenish  yellow  from  the  presence  of  pus,  or  red 
from  streaks  of  blood. 

The  Diagnosis  of  the  Cause  is  made  by  microscopical  examination 
of  a  smear  or  of  a  culture  of  the  secretions. 

To  obtain  secretions  for  bacteriological  examination  for  gonococci, 
tubercle  bacilli,  or  other  organisms: 

Sterilize  the  vagina  with  douches. 

Place  a  sterile  cotton  tampon  against  the  cervix  uteri. 

On  the  day  following  remove  the  tampon,  collect  the  secretions 
with  a  swab,  and  examine  immediately. 

The  early  differential  diagnosis  of  erosions,  both  simple  and  papil- 
lary, from  carcinoma  is  most  important.  Friability  and  bleeding 
upon  handling  with  fingers  or  instruments  and  board-like  induration 
are  most  reliable  clinical  signs  of  carcinoma.  Symptoms  are  not  to 
be  relied  upon,  because  erosions  may  give  all  of  the  typical  signs  of 
carcinoma,  and  beginning  carcinoma  may  give  rise  to  few  or  no  signs. 
For  absolute  diagnosis  microscopical  examination  should  be  made  of 
an  excised  part.  See  Differential  Diagnosis  in  Chapter  XXV.,  on 
Carcinoma  Uteri. 

Treatment  of  Chronic  Endocervicitis 

In  the  treatment  of  cervicitis  it  is  well  to  remember  the  physio- 
logical fact  that  irritation  at  the  opening  of  a  duct  will  stimulate  and 
increase  the  secretion  of  the  gland  or  glands  from  which  the  duct 
leads;  and,  conversely,  withdrawal  of  the  irritation  will  cause  a  decrease 
in  the  secretion.  The  same  is  pathologically  true  of  the  uterine  canal 
and  the  uterine  glands.  The  irritation  caused  by  endocervicitis  may 
increase  uterine  secretions.  Whatever  will  allay  irritation  of  the  cervix 
must  tend  to  relieve  the  excessive  glandular  activity. 

In  acute  or  recent  endocervicitis  the  treatment,  especially  if  the 
infection  be  gonorrhoeal,  should  be  strongly  disinfectant.  The  pur- 
pose is  to  prevent  extension  to  the  corpus  uteri  and  parametria.  First, 
clean  out  the  mucous  plug,  then  thoroughly  apply  the  solid  stick  of 
silver  nitrate  or  a  saturated  solution  of  iodine  in  95  per  cent,  carbolic 
acid  over  the  whole  intracervical  mucosa.  The  strong  tendency  of 
the  infection  to  spread,  and  the  consequent  danger  of  the  disease  being 
carried  to  the  corporeal  endometrium  by  the  careless  introduction 
of  instruments  past  the  internal  os,  should  be  kept  constantly  in 
mind. 

When  the  chronic  disease-process  has  penetrated  to  the  deep  mucous 
folds  and  glandular  pockets,  superficial  treatment  will  fail.  It  then 
becomes  necessary  to  destroy  the  infected  mucosa.  Deeply  acting 
caustics  may  accomplish  this,  but  the  resulting  cicatricial  contraction, 
especially  when  the  canal  is  not  very  patulous,  contraindicates  their 
use.  The  same'objection  in  less  degree  applies  to  removal  of  the  mucosa 
by  sharp  curettage.  Thorough  excision  and  covering  by  a  plastic 
operation  the  surfaces  thereby  exposed  are  usually  the  best  treatment. 


CHROMC  EXDOCEIiVKITIS  22.', 

Tlic  operation  of  SclirocdtT,  wliidi  fulfils  this  iiidicatiou,  is  jn'rfornicd 
as  follows: 

Schroeder's  Operation. — TIr-  jjaticut  iK-iiij,'  aiuesthetized  and  in  the 
lateroproiie  or  dorsal  position,  the  cervix  exposed  by  Sims'  or  Simon's 
speculimi  is  drawn  toward  tiie  vulva  and  divided  bilaterally  with 
scissors  to  or  beyond  the  uterovaj^inal  junction.  The  anteri(jr  and 
posterior  lips  are  then  sejjarated  widely  with  tenaeula.  The  condition 
is  now  like  that  of  extensive  bilateral  laceration  of  the  cervix.  The 
lateral  incision  should  be  deep  enough  so  that  when  the  lips  are  forced 
ai)art  all  the  diseased  intracervical  mucosa  may  be  exposed  and  excised. 


Vi'.l    K 


Figure  01. — Sf-hroedrrr',-  opfr;itiori.  first  step.  Lateral  di-\-i-:'jri  '.f  tiir-  r-f-rvix  uteri  with  straight 
sci.s.sors.     Posterior  lip  of  cervix  held  with  flat  vulsellum  forcep.i.     Donsal  positiou.     Simon  speculum. 

Figure  92. — Schroeder's  operation,  second  step.  Removal  of  diseased  cervical  mucosa,  preparatory 
to  folding  each  cervical  flap  upon  itself. 


The  anterior  and  posterior  flaps  are  now  turned  in  each  upon  itself 
and  united  with  sutures  to  the  intracervical  margins  of  the  wound. 
Two  or  three  sutures  are  required  to  secure  each  flap.  The  lateral 
incisions,  now  much  shortened  by  the  folding  in  of  the  flaps,  may  after 
suitable  denudation  be  closed  by  suture,  as  in  Emmet's  operation  for 
laceration  of  the  cervix.  Upon  comp'etion  of  the  operation  the  flap 
sutures  will  be  situated  deep  in  the  cervical  canal,  where  removal  of 
them  would  be  difficult.  They  should  therefore  be  of  catgut.  The 
lateral  sutures  should  be  of  silkworm  gut  or  chromic  catgut.  If  silk- 
worm gut,  they  should  be  removed  in  about  two  weeks.  The  opera- 
tion, if  well  done,  is  followed  by  permanent  cure  and  freedom  from 
stenosis.  (Jreat  ever.noii  through  the  os  externum,  gi\ing  the  outrolled 
mucosa  an  ulcerated  appearance,  is  due  usually  to  laceration  of  the 
cervix,  and  should  lie  treated  as  .such. 


224     INFECTIONS,   INFLAMMATIONS,  AND  ALLIED  DISORDERS 

In  rare  cases  pronounced  eversion  and  erosion  occur  in  the  virgin 
cervix,  giving  rise  to  soft,  spongy,  granular  masses,  which  should  be 

FiGUEE    94 


Figure  93 

JB 

In^ 

fi 

■1^ 

m'^y 

^^^ 

^pVI 

tttm 

WHBHi^\' 

\ 

/ 

Figure  95 


Figure  93. — Schroeder's  operation,  third  step.  Cut  margin  of  the  vaginal  portion  of  the  cervix 
uteri  united  with  the  cut  margin  of  the  intracervical  canal  at  the  angle  of  the  wound.  Three  sutures 
in  place  and  tied  on  the  anterior  lip.     Middle  suture  passed  but  not  tied  on  the  posterior  lip. 

Figure  9-t.-^Schroeder's  operation,  fourth  step.  Lateral  denudation  of  the  cervix  uteri  precisely 
as  it  would  be  done  in  trachelorrhaphy.     This  is  preparatory  to  the  introduction  of  the  lateral  sutures. 

Figure  95. — Schroeder's  operation,  fifth  step.  All  the  sutures  introduced  and  tied  on  one  side, 
thereby  rolling  in  the  exposed  cervical  mucosa,  the  first  suture  being  introduced  on  the  other  side. 
When  all  the  required  sutures  have  been  introduced  and  tied  the  operation  will  be  complete. 

Figure  96. — Schroeder's  operation,  complete.  The  sutures  in  the  cervical  canal  have  been  rolled 
in  and  are  almost  out  of  sight,  only  the  ends  sho'ndng.  Each  side  of  the  cervix  uteri  has  been  brought 
together  by  means  of  four  interrupted  sutures. 


removed  with  curved  scissors,  the  cut  surfaces    cauterized,  and    the 
cervix  dressed  with  strips  of  gauze  saturated  with  a  mixture  of  10  per 


CHRONIC  ENDOCERVICITIS 


225 


cent,  ammoniated  ichthyol  in  glycerin;  the  dressings  to  be  changed  daily 
until  the  surfaces  have  healed.  This  treatment  will  be  disappointing  if 
there  be  extensive  endometritis  above,  unless  that  also  be  included  in 
the  plan  of  treatment.  See  Treatment  of  Endometritis.  It  may, 
however,  be  wholly  satisfactory  if  the  inflammation  is  confined  essen- 
tially to  the  lower  cervical  mucosa.  If  it  fails,  Schroeder's  operation  is 
indicated. 


FiornE  97 


Figure  'JS 


FiGrRE  97. — Cervical  canal  distended  by  secretions.  This  is  due  to  obstruction  at  the  internal 
OS  uteri  and  partial  or  complete  closure  of  the  external  os.  Such  obstruction  and  closure  are  frequently 
consequent  upon  cicatricial  contraction  following  cauterization. 

Figure  98. — Pinhole  os  of  congenital  origin  in  a  partially  developed  uterus  .-1,  shows  the  pinhole 
OS  in  section;  B,  shows  the  pinhole  os  as  seen  through  the  speculum. 


Polypoid  endocen-icitis,  so  called,  requires  the  removal  of  the  adenoid 
growths  by  means  of  the  sharp  curette  or  the  scissors,  as  shown  in 
Figure  90.  ^Yhen  glandular  disease  is  extensive,  it  may  be  necessary 
to  perform  Schroeder's  operation. 

Pinhole  Os. — In  nulliparae  the  internal  and  external  ora  are  some- 
times so  narrow  that  the  cervical  secretions  are  retained  and  distend 
the  cervical  ca^■ity  quite  beyond  its  normal  size.  Sometimes  the 
internal  os  is  open,  and  the  corpus  is  enlarged  correspondingly  from 
the  same  cause.  The  retained  secretions  give  rise  to  great  irritation 
and  reflex  disturbances.  The  rational  treatment  is  to  open  the  canal 
by  free  incision  of  the  external  os,  and,  if  necessary,  by  dilatation  of  the 
internal  os.  Exploratory  curettage  will  show  whether  the  endometrium 
requires  thorough  dilatation,  therapeutic  curettage,  and  cauterization. 

The  pinhole  os  usually  is  congenital  and  chiefly  confined  to  nullip- 
arae. Figure  98  B.  It  may,  however,  occur  as  the  result  of  cauteri- 
zation or  of  too  tight  closure  in  the  operation  for  laceration  of  the 
cervix.  The  constricted  external  os  may  be  opened  by  incision  or  by 
forcible  dilatation.  After  the  application  of  either  of  these  methods  the 
OS  is  liable  to  recontract.  Schroeder's  operation,  which  gives  permanent 
results,  is  therefore  preferable. 
15 


CHAPTER  XVI 
CHRONIC   ENDOMETRITIS 

In  studying  endometritis,  one  should  remem})er  that  the  infected 
endometrium  is  usually  only  a  part  of  an  infected  uterus,  and  that 
this  infection  in  many  cases  is  not  limited  to  the  uterus,  but  in  vari- 
able degree  may  involve  the  uterine  appendages  and  parametria. 

The  layer  of  columnar  ciliated  epithelium,  the  connective  tissue, 
the  blood-  and  lymph-vessels,  and  the  nerves  which  compose  the 
endometrium,  are,  like  the  similar  structures  in  the  cervix,  subject  to 
chronic  inflammation.  Certain  pathological  changes  result  from  this 
infection,  and  are  the  essential  factors  of  chronic  endometritis. 

Etiology  of   Chronic  Endometritis 

The  predisposing  and  exciting  causes  are  the  same  as  already  de- 
scribed for  vulvitis,  vaginitis,  and  acute  metritis.  A  very  usual  source 
of  the  infection  is  the  cervical  mucosa.  And  an  untold  amount  of  in- 
fection is  carried  to  the  endometrium  by  useless  and  meddlesome 
intra-uterine  treatment. 

Pathology  of  Chronic  Endometritis 

It  is  here  important  to  remember  that  not  every  increased  secre- 
tion is  proof  of  endometritis.  There  may  be  an  effort  on  the  part  of 
the  mucosa  to  relieve,  by  an  increased  secretion,  a  chronic  venous  con- 
gestion in  and  about  the  uterus;  or  the  mucous  membrane  of  the  uterus 
in  common  with  that  of  other  organs  may  be  engaged  in  vicarious 
elimination  of  effete  matter  which  the  proper  excretory  organs  have 
failed  to  eliminate;  such  conditions  strongly  predispose  to  and  are 
present  in  a  proportion  of  cases  of  endometritis,  but  are  not  in  them- 
selves endometritis. 

In  studying  endometritis  microscopically  the  beginner  may  be  at  a 
loss  to  account  for  occasional  irregular  appearances  of  the  uterine 
glands,  due  to  invagination  of  the  glands.  Figures  99  to  106,  drawn 
after  a  scheme  suggested  by  Amann,  will  explain  these  irregularities. 

The  general  pathology  has  been  forecast  under  Acute  Metritis. 
The  special  pathology  will  be  presented  in  the  description  of  the 
different  histological  and  clinical  forms. 

Pathological  changes  in  the  endometrium  are: 
Glandular  hypertrophy. 
Glandular  hyperplasia. 
Interstitial  changes. 
( 226 ) 


(  IIUOS  K     K.\  1)1). METRITIS 


Vicvnv.  '.I'J 


l''|c;iiiK    1(« 


f 


I'KilJRE 

100 

/•■'I         % 

k 

71  ■ 

v 

Jl 

Figure 

101 

FifiinK   lot 


[  : 


Figure  102 


Figure  106 


•!■>■••'•  T'<.>.._      V" 


■'>\ 


:i:^.--^' 


■>fe. 


Figures  99-106 


Explanation  of  scheme  of  gland  invagination.  Figures  99  to  102  show  longitudinal  sections  of 
invaginated  uterine  glands:  Figures  103  to  106  show  cross-sections  of  the  same  gland.  The  glands 
shown  in  longitudinal  section  are  crossed  each  by  a  line  showing  the  plane  at  which  the  cross-sec-tions 
are  made.  Figure  99  shows  the  invaginated  fundus  of  a  gland  with  secondary  eversion.  Figure  102 
shows  intraglandular  papillani-  invagination  of  a  gland  epithelium  from  the  side  of  the  gland.  Figure 
100  shows  simple  invagination  of  the  fundus  of  a  gland.  Figure  101  shows  the  inner  and  outer 
segments  regular  and  the  middle  segment  invaginated. 


228      INFECTIONS,   INFLAMMATIONS,   AND   ALLIED   DISORDERS 

Glandular  Hypertrophy. — The  normal  uterine  glands  are  tubular, 
approximately  straight,  branch  but  little,  run  almost  perpendicular 
to  the  surface,  may  extend  to  the  muscularis — that  is,  to  the  myome- 
trium; and  but  rarely  dip  down  so  far  as  to  penetrate  even  to  the  super- 
ficial layer  of  it.  In  hypertrophic  endometritis  the  glands  increase  in 
size,  become  proportionately  irregular  in  outline,  pursue  a  direction 


Figure   107 


^♦■^iij^t-t*  •-H\_^ 


.---■" 


4 


1^ 


?) 

f  ^ 


J'' 

it 


i\ 


i  t 


/■ 


^J 


I 


^ 


Figure   108 


PakKcP.  . 


Figure  107. — Xonaal  uteriuo  muroia  in  a  woman  twenty-five  years  old.  Four  main  glands  are 
shown.  The  small  cross-sections  are  branches  of  the  main  gland.  The  glands  dip  down  to  and  very 
little  into  the  muscularis.     40  diameters. 

Figure  108. — Normal  uterine  mucosa  after  the  menopause.  The  size  of  this  drawing  as  related 
to  that  of  Figure  107  shows  the  shrinkage  which  takes  place  at  the  menopause.  The  uterine  glands 
have  been  obliterated  almost  entirely  by  atrophy.  This  condition  somewhat  resembles  that  of  inter- 
stitial endometritis.     40  diameters. 


less  perpendicular  to  the  surface,  dip  more  deeply,  develop  numerous 
branches,  become  tortuous;  and  in  consequence  of  dilatation  in  some 
places  and  constriction  in  others,  frequently  take  on  great  irregularity 
of  lumen.  There  is  lining  the  glands  a  single,  and  only  a  single  layer  of 
columnar  epithelium,  with  enlargement  of  the  individual  epithelial  cells. 
Such  is  the  picture  of  chronic  hypertrophic  glandular  endometritis. 
(Plate  IV.,  Figure  1.) 


PLATE    IV 


FIGURE   1 


^^■^•^^^^■ 


r     ^f"^    ■f€CM% 


^, 


^lfer.f^?^t?^i^ -^^ 


.^^t^^'K*^ 


FIGURE  2 


'^    V- 

~5#; 

<..  ,    - 

- 

.^^' 

> 

^ 

' 

' '  >\\ 

-^ 

"■ 

/  -  ^^ 

PARKEK 

FIGURE  3 


w- 


1%^^.^ 


PLATE    V 


If- 


n 


\Sk 


!S^S -=«.<•  jilT^ 


yARK£.R/ 


Interstitial  Endometritis  (Cystic). 

The  free  mucous  surface  is  shown  in  the  upper  margin  of  the  picture.  .  A  gland 
in  longitudinal  section  penetrates  the  stroma  on  the  left.  Single  layers  of  glandular 
epithelium  in  some  places  have  been  detached  and  destroyed.  In  some  of  the 
glands  the  epithehum  lining  is  intact,  in  others  it  partially  has  been  shed.  The 
large  cystic  gland  in  the  centre  of  the  figure  shows  much  detached  epithelium 
which  at  some  points  still  preserves  its  form  and  in  others  has  become  degen- 
erated. Near  the  centre  of  the  figure  is  an  enormously  large  bloodvessel,  and 
scattered  over  the  field  are  numerous  small  vessels,  all  having  very  thick  walls. 
The  interglandular  stroma  here  is  fibrous  in  character,  and  the  quantity  of  it  is 
much  increased  while  the  glands  are  decreased.     30  diameters. 


ci/h'oMc  i':.\ DOM  i-rrhTi'/s  221) 

(ilitiidiihir  II i/jJcrpld.sKi.  'I'liis  form  not  iiit'rc(|ii('ii( Iv  presents  all  the 
essentials  of  the  hypertrophic  \ariety,  hut,  as  a  (listiuguishiiifi;  cliar- 
aeteristic,  will  show  increase  in  the  number  of  glands;  this  increase 
necessarily  takes  ])lace  at  the  expense  of  the  interfi;lan(lular  connective 
tissue,  so  that  the  interglandular  spaces  no  lonncr  maintain  the  normal 
ratio  of  four  times  the  diameter  of  the  glands;  hut  may,  on  the  con- 
trary, almost  wholly  give  way  to  the  encroachments  of  the  newly 
formed  glands.  Increase  in  the  number  of  glands  results  from  a 
process  of  budding  of  the  glands  or  of  invagination  from  the  surface 
I'pithelium.      Figures  9!)  to  lOb. 

This  hypcrj)lasia,  sometimes  called  hijperpla.sfic  glandular  viidoiiicirdis, 
was  regarded  by  the  older  pathologists  as  a  new  growth,  and  some- 
times is  called  wrongly  benign  adenoma.  The  consensus  of  o])inion  is 
in  favor  of  attributing  to  such  growths  an  inflammatory  origin,  and 
of  placing  them  in  an  intermediate  position  between  inflammatory 
growths  and  new  formations.  The  term  adenoma  should  be  used  to 
describe  not  hyperplasia,  but  malignant  glandular  growths.  (Plate 
IV.,  Figure  2.) 

Iniersiitial  Changes  usually  are  characterized  by  increase  in  the  con- 
nective tissue  of  the  endometrium  at  the  expense  of  the  glandular 
elements,  and  are  therefore  the  reverse  of  glandular  hyperplasia.  In 
the  normal  endometrium  the  connective  tissue  is  embryonal  in  type 
and  composed  of  spindle  cells  loosely  associated.  In  interstitial  endo- 
metritis these  cells  increase  and  mature  into  fibers  which  separate  the 
glands  widely.  The  effect  is  to  shut  oflf  the  nutrition  of  the  glands, 
and  thereby  to  crush  out  and  partially  or  completely  to  destroy  them. 
The  outlets  of  the  glands  may  close  and  give  rise  to  retention  cysts; 
this  is  called  cystic  endometritis.  Finally,  the  endometrium  may  become 
a  thin  layer  of  contracted  cicatricial  tissue,  not  unlike  that  produced 
by  the  atrophic  changes  of  old  age.    (Plate  V.) 

Glandular  and  interstitial  endometritis  often  are  combined  in  vary- 
ing proportions.    Part  or  all  of  the  endometrium  may  be  involved. 

Mucous  Polyps  of  the  uterus,  commonly  called  polypoid  endometritis , 
are  apt  to  be  developed  when  there  is  a  concurrence  of  interstitial 
endometritis  with  great  glandular  enlargement;  they  are  marked  by 
excessive,  diffuse,  glandular,  and  vascular  development  and  by  cystic 

Explanation  of  Plate  IV 

Figure  1. — Hj-pertrophic  glandular  endometritis.  The  glands  are  swollen  and  tortuous,  but  not 
increased  in  number.  In  the  upper  left-hand  corner  is  a  triangle  of  uterine  muscular  tissue  contain- 
ing five  glands.  The  dipping  of  these  glands  far  into  the  muscular  tissue  may  sometimes  raise  the 
suspicion  of  carcinoma.  The  remaining  gland.s  are  surroimded  by  a  stroma  of  embryonic  cells — that 
is,  the  cells  which  produce  connective  tissue.  This  field  contains  seven  blood-vessels,  indicated  by  the 
red  color.  In  the  middle  of  the  left  half  are  four  glands  all  having  tangential  cuttings.  This  is" mis- 
taken sometimes  for  proliferation  of  epithelium.  Similar  cuttings  of  two  glands  appear  in  the  lower 
part  of  the  picture  on  the  right  side.  Small  round  cells  of  inflammation,  as  indicated  by  dark  staining, 
appear  here  and  there  in  groups  and  sometimes  widely  scattered.     SO  diameters. 

Figure  2. — Hyperplastic  glandular  endometritis  (hemorrhagic).  Observe  some  of  the  glands 
invaginated  and  therefore  characteristic  of  hyperplasia.  The  blood-vessels  and  the  extravasated 
blood  are  seen  scattered  over  the  field.  Also  much  congestion  is  seen  near  the  surface  epithelium  at 
the  upper  margin.     15  diameters. 

Figure  3. — A  part  of  Figure  2  highly  magnified.  Observe  the  hemorrhagic  and  congested  areas, 
the  full  blood-vessels,  the  swollen,  invaginated,  and  tortuous  glands,  which  are  increased  in  size  and 
number.     A  characteristic  specimen  of  hemorrhagic  endometritis.     100  diameters. 


230      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

degeneration  of  the  glands.  Some  of  the  cystic  glands  have  the  char- 
acter described  under  interstitial  endometritis;  others  become  fungoid 
projections  upon  the  surface — that  is,  small,  soft,  polypoid  bodies,  like 
nasal  polypi;  often  pedunculated,  variable  in  size,  and  swollen  from 
retained  secretions.  These  changes  make  the  endometrium  excessively 
thick,  soft,  and  oedematous.  The  excessive  glandular  and  vascular 
enlargement  explains  the  chief  subjective  symptoms — exhaustive 
glandular  secretions  and  hemorrhage.  These  polypoid  bodies  are  not 
to  be  regarded  as  new  growths,  and  therefore  should  not  be  classed 
as  adenomata. 

Figure  109 


Polypoid  endometritis;  removal  by  curettage. 


In  So-called  Post-ahortum  Endometritis,  abortion  may  be  a  cause  or 
an  effect.  The  inflammation  which  is  rather  interstitial  than  glandular, 
causes  an  arrest  of  involution  in  the  mucous  membrane  at  the  site  of 
the  ovule  and  of  the  adjacent  mucosa — i.  e.,  of  the  decidua  serotina  and 
decidua  vera.  The  arrest  of  involution  in  localized  areas  may  give 
rise  to  islands  of  decidual  cells  circumscribed  within  the  surrounding 
mucous  membrane  by  the  round  cells  of  inflammation. 

There  is  a  chronic  form  of  intractable,  not  to  say  incurable  endo- 


PLATE    VI 


FIGURE  1 


if 


#  !■>       4  4 


-jlfev^ 


J^i--^" 


''-g.-i-  gry 


FIGURE  2 


FIGURE  8 


CIIIiOMC   ESUOMKTRITIS 


231 


metritis  cliaractorized  l)y  the  detaehment  of  a  nieinhraiioiis  structure 
troni  the  endDUietriuni  in  t'raf^nieuts  ov  as  a  whole,  and  tiie  expulsion 
of  it  with  hd)or-hke  pains,  from  the  uterus.  It  may  occur  at  puberty, 
with  the  first  menstruation,  and  continue  indefinitely,  or  may  be^in 
at  any  time  during  menstrual  life.  The  character,  quantity',  and 
completeness  of  the  thrown-oft'  membrane  vary  with  individuals,  and 
from  time  to  time  in  the  same  individual.  The  process  is  ordinarily 
described  exfoliative  endometritis;  it  gives  rise  to  an  aggravated  form 
of  painful  menstruation  known  as  viemhranous  (h/ftmenorrhcea. 

Fig  u  HE   110 


Cast  from  uterine  ca\nty  in  exioiiative  endometritis — membranous  dysmenorrhoea,  natural  size. 

After  the  menopause,  when  the  uterus  has  undergone  a  condition 
known  as  senile  endometritis,  it  is  subject  to  a  most  harassing  form 
of  purulent  inflammation  which  is  usually  the  relic  of  an  earlier  infec- 
tion, and  due  to  the  action  of  bacteria  on  the  atrophic,  less  resisting 
endometrium.     The  discharge  is  commonly  offensive,  purulent,  often 


Explanation  of  Pl.^te  VI 

Figure  1. — Post-abortum  endometritis.  .Section  of  endometrium  removed  by  the  curette  after 
abortion.  The  upper  left-hand  corner  contains  decidual  cells  with  two  smill  blood-vessels.  The 
remainder  of  the  field  is  occupied  by  chorionic  villi.  In  most  of  the  villi  blood-vessels  either  in  longi- 
tudinal or  cross-section  are  shown.  The  \-illi  are  surrounded  by  two  layers  of  cells,  the  inside  layer 
being  the  ectodermal  epithelial  layer  of  Langhans,  the  outer  layer  being  the  uterine  epithelial  layer 
of  the  chorion — SO  diameters. 

Figure  2. — Menstrual  decidua  from  membranous  dysmenorrhoea  as  seen  by  the  microscope.  The 
upper  border  is  composed  of  surface  columnar  epithelium  somewhat  flattened.  There  are  three  glands 
lined  witii  columnar  epithelium.  The  remainder  of  the  field  is  made  up  of  decidual  cells  among  which 
are  scattered,  especially  in  the  centre  of  the  field,  numerous  small  round  cells  of  inflammation.  80 
diameters. 

Figure  3. — Uterine  decidua  commonly  cast  off  in  tubal  pregnancy  at  the  time  of  spurious  labor. 
The  outer  margins  and  open  spaces  are  torn  and  ragged.  The  drawing  shows  three  blood-vessels  full 
of  blood.  The  decidual  cells  are  large  and  irregular  with  small  nuclei.  The  decidua  of  tubal  preg- 
nancv  seldom  .sliov.  s  <rlands  ar.d  none  are  seen  here.     SO  diameters. 


232     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

tinged  with  blood,  and  is  so  irritating  as  sometimes  to  cause  a  most 
distressing  pruritus  vulvce.  The  infection  may  destroy  the  exhausted 
senile  mucosa  and  penetrate  into  the  muscularis.  Cicatricial  stenosis 
and  even  complete  cicatricial  occlusion  in  the  uterine  canal,  usually 
at  the  internal  os,  may  occur,  causing  the  uterine  secretions  to  be 
retained  and  the  distended  organ  to  become  a  thin-walled  retention- 
cyst — pyometra  or  hydrometra,  according  as  the  retained  fluid  is  purulent 
or  watery;  this  obstruction  to  the  drainage  of  secretions  aggravates 
the  disease,  and  the  organs  may  remain  large  from  distension.  The 
retained  products  of  senile  endometritis  may  give  rise  to  reflex  dis- 
turbances, in  nutrition,  and  the  systemic  depression,  even  to  general 
chronic  toxaemia.  In  most  cases,  however,  of  senile  endometritis  the 
uterus  is  not  enlarged,  but  rather  is  in  a  state  of  full  senile  atrophy. 

The  microscopical  changes  are  like  those  of  atrophic  interstitial 
endometritis,  already  described.  The  glands  and  epithelial  elements 
in  the  last  stages  of  the  disease  are  destroyed  and  the  submucous 
structures  laid  bare.  The  exposure  of  fibrous  tissue  is  favorable  to  the 
development  of  suppuration,  granulation,  and  ulceration — three  char- 
acteristics of  senile  endometritis.  The  disease  may  be  corporeal  or 
cervical,  or  both.  The  offensive  discharge,  the  occasional  uterine 
enlargement,  and  systemic  depression  may  lead  to  confusion  between 
this  disease  and  uterine  cancer.  Cicatrization  may  bring  about  a  spon- 
taneous cure.  Usually,  however,  unless  cut  short  by  treatment,  the 
suppuration  persists. 

Symptoms  of  Chronic  Endometritis 

The  symptoms  of  acute  endometritis — that  is,  hypogastric  pain, 
pelvic  weight,  rectal  and  vesical  tenesmus — may  in  some  degree  con- 
tinue, but  as  the  disease  becomes  chronic  they  cease  to  predominate; 
in  their  place  comes  an  inconstant  symptom-group  which  always 
contains  some  of  the  following  factors: 

Pain. 

Abnormal  secretions  and  uterine  hemorrhage. 

Sterility  and  frequent  abortions. 

Systemic  and  reflex  disorders. 
The  above  symptoms  often  are  observed  in  other  disorders,  and  are 
therefore  not  strongly  characteristic. 

Pain. — Obstructive  dysmenorrhcea  may  result  from  cicatricial 
stenosis,  especially  if  the  menstrual  blood  coagulates  in  the  uterus 
and  is  forced  out  by  strong  contractions;  the  pain  will  then  be  inter- 
mittent. Intermenstrual  pain  from  the  expulsion  of  accumulated 
secretions  in  the  uterus  may  occur  in  the  same  way.  The  excessive 
menstrual  pain,  like  labor-pain,  in  exfoliative  endometritis  has  already 
been  mentioned.  Congestive  dysmenorrhcea  often  precedes  the  flow, 
but  subsides  as  soon  as  the  engorged  vessels  are  relieved  by  it.  The 
uterine  and  other  pelvic  nerves  already  sensitive  from  neuritis  when 
crowded  by  congested  vessels,  easily  become  the  seat  of  great  menstrual 


CflROMC   KSDOMKTRITIS 


233 


and  intermenstrual  ])ain  or  disconit'ort;  this  accounts  for  the  coiuuionly 
()l)ser\e(l  clra^'^in<;-  sensations  in  the  j)el\-is,  for  the  haekache  and  for 
the  occasional  \i'sical  and  rectal  tenesnnis. 

The  Abnormal  Secretions,  sometimes  described  by  the  vague  and 
poj)uIar  fcnii,  leucurrho'a,  may  be  catarrhal  or  purulent,  or  muco- 
purulent and  often  contain  blood.  Hemorrhaj^es  may  be  occasional, 
frecpient  or  constant,   slight'  or  j)rofuse. 


FinuuE   111 


Figure  112 


3^  Sa      «      '£     <- 


>5 


-XT' 


l^Z 


/Mr^ 


Fii;uRE  111. — Hypfijjlastic  gljunhilar  iridniiiftritis  The  glands  are  increased  in  size  and  number, 
greatly  tortuous,  and  dip  decidedly  into  the  niuscularis  The  interglandular  spaces  are  much  decreased. 
This  condition  sometimes  is  called  benign  adenoma.     Semidiagrammatic. 

Figure  112. — Same  as  Figure  111.  Modified  in  the  lower  part  by  carcinoma,  commonly  called 
adenocarcinoma.  There  is  great  rarefaction  of  stroma  and  in  the  carcinomatous  part  the  glands  are 
so  tortuous  and  atypical  that  they  cannot  be  traced.  Carcinoma  is  demonstrated  here  by  the  breaking 
through  the  tunica  propria  into  the  stroma  and  the  invasion  of  the  stroma  by  proliferated  gland  epi- 
thelium which  also  fills  the  glands.  The  lower  left-hand  corner  shows  a  gland  which  shows  much  cell 
proliferation,  and  which  may  be  regarded  as  the  earliest  stage  of  cancer  formation,  but  not  a  condition 
upon  which  a  positive  diagnosis  should  be  made.     Semidiagrammatic. 


Sterility  and  Abortion  are  associated  frequently  with  the  disease. 
Sterility  may  result  from  complicating  ovaritis  or  obstruction  in  the 
Fallopian  tubes,  or  from  destruction  of  the  spermatozoa  by  the  ab- 
normal uterine  secretions,  or  from  their  mechanical  exclusion  from  the 
uterus  by  the  plug  of  tenacious  mucus  usually  found  in  endocervicitis; 
or  from  the  hostile  influence  of  the  diseased  uterine  mucosa  on  the 
ovule.  The  failure  of  the  ovule  to  implant  itself  upon  the  mucosa  may 
give  rise  to  no  subjective  symptoms,  and  the  consequent  fact  of  early 
abortion  may  pass  unrecognized.  Indeed,  the  habit  of  early  abortion 
mav  become  established. 


234     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

The  Systemic  and  Reflex  Disorders  are  chiefly  referable  to  the 
nervous  system.  Among  them  are  neuralgia,  indigestion,  malnutri- 
tion, nervous  dyspepsia,  anaemia,  chlorosis,  spinal  irritation,  and 
hysteria.  Endometritis  may  be  a  cause  or  an  effect  of  the  above  asso- 
ciated disorders,  or  together  with  them  may  be  a  concurrent  result 
of  some  common  cause,  or  may  have  primarily  no  pathological  con- 
nection with  them.  The  nervous  symptoms  usually  are  most  pro- 
nounced during  the  few  days  before  menstruation,  and  may  be  very 
marked  during  the  flow. 

Diagnosis  of  Chronic  Endometritis 

A  diagnosis  may  be  inferred  from  a  history  of  acute  genital  infection 
— sometimes  absent — together  with  the  symptoms  outlined  above, 
and  may  be  substantiated  by  curettage  and  microscopical  examination 
of  the  scrapings.  Digital  examination  will  in  many  cases  show  increased 
size  and  hardness  of  the  uterus,  and  is  especially  essential  as  a  means 
for  the  detection  of  complications,  such  as  tumors,  displacements,  and 
circumuterine  inflammations. 

Differential  Diagnosis  requires  not  onl\'  a  distinction  between  the 
different  forms  and  phases  of  endometritis,  which  has  been  set  forth 
under  pathology,  but  also  the  elimination  of  all  other  conditions,  uterine 
and  extra-uterine,  which  give  rise  to  localized  pain,  abdominal  secre- 
tions, and  hemorrhage;  among  these  conditions  are: 
Salpingitis,  vulvovaginitis,  and-  pelvic  abscess.  • 
Malignant  and  benign  tumors. 
Early  abortion. 
Tubal  pregnancy. 

A  discharge  from  the  vagina  or  from  the  Fallopian  tube  may  be 
mistaken  for  the  product  of  endometritis.  Inspection  will  show  whether 
the  discharge  comes  from  the  uterus  or  not.  The  tube  may  refill  and 
empty  itself  through  the  uterus  at  intervals,  giving  rise  to  periodical 
expulsive  pains  in  the  uterus — colica  scrotonnn.  Pus  from  a  pelvic 
abscess  is  recognized  by  finding  the  sinus  through  which  it  discharges; 
such  a  sinus  often  opens  into  the  vagina  near  the  uterus,  seldom  into 
the  uterus. 

The  diagnosis  between  endometritis  and  malignant  disease  will 
depend,  first,  upon  the  history  of  the  case,  the  nature  of  the  discharge, 
and  conjoined  examination;  second,  upon  the  findings  of  the  curette 
and  the  microscope.  The  discharges  from  carcinoma  and  sarcoma, 
unlike  those  of  endometritis,  are  more  profuse,  more  offensive,  more 
watery,  and  usually  contain  more  blood.  Cachexia  and  other  systemic 
disorders  are  quite  marked  in  sarcoma  and  carcinoma,  but  usually 
absent  or  slight  in  endometritis. 

Figures  111  and  112  show  in  a  diagrammatic  way  the  transition  from 
hyperplastic  endometritis  to  adenocarcinoma. 

The  differential  points  between  the  two  forms  of  chronic  glandular 
endometritis  and  carcinoma  are  shown  in  the  illustrations  on  endome- 


( iJiioxn ■  I'.snoM F/riii ris 


235 


tritis  and  carcinoiiui  and  in  the  follow  iii^  |)arallcl  colnnnis.    St-o  Chapter 
i)n  Carcinoma  I  tori. 


Glnit'litlar  hijpcrlrophic 
tmtomitrilis 

1.  Glands    increased    in    size 
but  not  in  number. 

2.  Xo  proliferation   of  gland 
epithelium. 

3.  Gland  structures  nearly  or 
quite  typical  in  outline. 


4.  Hypertropuied  epithelium 
confined  within  the  limits  of  the 
tunica  propria. 


.5.  Gland  tissue  does  not  in- 
vade muscularis  deeply. 

G.  Can  trace  tortuous  glands. 


Stroma    normal    in    quan- 


8.  Glands  evenly  distributed. 


Glandular  hyperplanlic 
eiitlometrilis 

1.  Glands    increased    in    size 
a:id  number. 

2.  Proliferation  of  gland  cpi- 
epithelium. 

3.  Gland  stnictures  more  tor- 
tuous in  outline. 


4.  Proliferation  confined 
within  the  limits  of  the  tunica 
propria. 


.5.   Gland  tissue  does  not  in- 
vade muscularis  very  deeply. 

0.   Can  trace  tortuous  glands. 


7.  Stroma  decreased  in  quan- 
tity, but  clearl>-  defined  froni 
glands.  Simple  filling  of  gland 
lumen  with  epithelium  does  not 
necessarily  denote  malignancy 
so  long  as  epitheUum  is  con- 
fined within  basement  mem- 
brane, /.  e.,  within  tunica  pro- 
pria. 

S.  Glands  evenly  distributed. 


Ailfiiocarcinoma 

1.  Glands  very  greatly  in- 
creased in  size  and  number. 

2.  \'ery  great  proliferation  of 
gland  epithelium. 

3.  Gland  structures  very 
atypical  in  outline.  See  Fig- 
ure 150. 

4.  The  proliferating  gland 
epithelium  has  broken  through 
the  tunica  propria  and  is  in 
direct  contact  with  intergland- 
ular  connective  tis.sue,  and  is 
multiplj-ing  in  an  atypical 
manner. 

.5.  Gland  ti.ssiie  may  very 
deeply  invade  muscularis. 

(i.  Glandular  labyrinth:  can- 
not trace  tortuous  and  atvpical 
gland.- 

7.  Great  rarefaction  of  stro- 
ma, so  that  glands  touch  one 
another.  Glands  have  broken 
through  basement  membrane 
and  invaded  interglandular 
spaces  and  muscularis.  See 
Chapter  XXMII. 


S.  Gland    elements    may 
distributed  ver\-  unevenlv. 


be 


Tlie  distinction  between  endometritis  and  sarcoma  is  difficult,  and 
in  early  sarcoma  sometimes  impossible.  The  followino;  points  are 
significant: 


Endonftritix 

1.  Progress  not  rapid  after  the  acute  stage. 

2.  Cells  do  not  vary  in  size  or  .shape. 

.3.   Walls  of  blood-vessels  clearly  separate  cells 
from  blood  supply. 


4.   Endometritis  first  involves  superficial  struc- 
ture, and  later  may  involve  deeper  structure. 


Sarcoma 

1.  Progress  verj-  rapid,  especially-  in  the  small 
round-cell  variet>'. 

2.  Vary  most  widely. 

3.  Intimate  relation  of  blood  spaces  to  cells. 
Walls  of  vessels  may  be  absent,  leaving  only 
blood  spaces. 

4.  Sarcoma  often  involves  deeper  la\er    first. 


Benign  tumors,  such  as  myomata,  so  small  even  as  to  be  impalpable, 
may  cause  hemorrhage.  The  recognition  of  them  may  require  intra- 
uterine dilatation  and  exploration,  removal  and  microscopical  examina- 
tion.   Large  growths  are  readily  recognized  on  palpation. 

The  membranes  thrown  off  in  the  form  of  dysmenorrhoea  closely 
resemble  in  gross  appearance  those  of  early  abortion  and  tubal  preg- 
nancy. The  differential  diagnosis  between  these  three  conditions  is 
therefore  important: 


236      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 


Exfoliative  endometritis 
1.   No  history  of  pregnancy. 


2.  DysmenorrhcBic  pain  and 
discharge  of  membrane  at  each 
menstrual  epoch. 


3.   No  enlargement  of  uterus 
or  Fallopian  tube. 


4.   Chorionic  villi  and  amnion 
absent. 


5.   No  foetus. 


6.  Membrane  may  be  exact 
cast  of  endometrium  or  may 
be  in  shreds. 


7.  Usually  incurable. 


Early  abortion 
1.   History  of  pregnancy. 


2.   Discharge     of     membrane 
with  pain  at  time  of  abortion. 


3.  Enlargement  of  uterus,  but 
not  of  Fallopian  tube. 

4.  Chorionic  villi  and  amnion 
present. 


5.  Foetus  discharged  from 
uterus. 

G.  Membranes  may  envelop 
foetus  and  may  be  cast  off  whole 
or  may  be  in  fragments  or 
shreds. 

7.  Self-limited  or  curable  by 
treatment. 


Tubal  pregnancy 

1.  Atypical  history  of  preg- 
nancy. 

2.  Discharge  of  decidual 
membrane  usually  between  the 
fourth  and  ninth  week  of  preg- 
nancy. 

3.  Enlargement  of  Fallopian 
tube  on  affected  side. 

4.  Absent  from  uterus.  Chor- 
ionic viHi  and  amnion  in  Fal- 
lopian tube. 

5.  No  foetus  discharged  from 
uterus. 

6.  Membrane,  not  associated 
with  fcetus,  cast  off  entire  or 
in  irregular  fibrous  fragments. 


7.   Not  incurable. 


Prognosis  of  Chronic  Endometritis 

The  mild  infection  usually  called  simple  endometritis  is  self-limited 
or  yields  readily  to  systemic  treatment.  The  strongly  infectious  cases 
are  protracted  not  to  say  intractable.  Apparent  cure  or  improvement 
often  is  followed  by  relapse.  Even  surgical  treatment  may  be  disap- 
pointing. The  prognosis  is  discouraging  in  gonorrhoeal  infection  and 
particularly  so  in  interstitial,  exfoliative,  senile,  and  tubercular  endome- 
tritis. The  question,  whether  the  diseased  mucosa  can  be  restored  to 
function  will  depend  upon  the  extent  to  which  it  has  been  impaired 
bv  disease  or  must  be  destroved  by  treatment. 


Treatment  of  Chronic  Endometritis 

The  treatment  varies  with  the  structures  involved,  the  nature  of 
the  infection,  the  chronicity  of  the  disease,  and  with  the  preponder- 
ance of  systemic  or  local  condition.  The  treatment  of  a  gonococcus 
infection  might  have  to  be  energetic  and  strong,  while  a  milder  infection 
would  require  only  simple  or  expectant  treatment.  Obstinate  cases  of 
long  standing  may  yield  only  to  the  most  radical  surgical  measures. 
It  is  better  to  distinguish,  on  the  one  hand,  the  non-purulent  cases  of 
uterine  catarrh  in  which  general  circulatory  disturbances — predispos- 
ing causes — predominate;  and,  on  the  other  hand,  the  cases  in  which 
infection — i.  e.,  exciting  causes — predominate:  The  septic  element  is 
not  confined  to  the  second  class,  nor  the  circulatory  element  to  the  first. 
An  appreciation  of  the  foregoing  will  suggest  the  following  division  of 
treatment : 

1.  Systemic  treatment. 

2.  Topical  treatment. 

3.  Surgical  treatment. 

1 .  Systemic  Treatment. — Systemic  treatment  is  applicable  to  a  very 
large  class  of  cases,  sometimes  called  subinflammatory,  which  arise 
not  so  much  from  local   infection  as  from  stagnation  of  the  general 


CHRONIC  ENDOMETRITIS  237 

circulation.  The  stagnation  is  associated  not  infrequently  with  dis- 
orders of  tiic  heart,  huifjs,  liver,  kidneys,  or  with  such  disorders  as 
anivmia,  rheumatism,  and  gout.  The  uterus  may  participate  in  the 
general  circulatory  disturbance  and  take  on  a  catarrhal  condition.  In 
this  class  of  cases  the  catarrh  usually  involves  not  only  the  uterus,  but 
also  extrapelvic  organs,  especially  the  organs  of  the  respiratory,  diges- 
tive, and  urinary  systems.  The  mucous  membranes  generally  become 
less  resistant  and  therefore  more  liable  to  infection.  Catarrh  is  often 
the  vicarious  act  of  a  mucous  membrane  to  throw  ofi'  waste-products 
which  it  would  not  normally  have  to  eliminate  at  all.  When  the  mem- 
brane is  reliexed  of  such  unnatural  function  the  resistance  to  the 
bacteria  is  increased,  and  in  this  way  the  discharge  may  cease. 

It  is  clear  from  the  foregoing  that  in  the  absence  of  marked  local 
infection  the  treatment  should  be  not  so  much  local  as  systemic;  in- 
deed, when  the  uterine  discharge  is  mainly  consequent  upon  systemic 
causes,  local  treatment  may  be  useless,  perhaps  injurious.  On  the  other 
hand,  the  uterus  may  participate  in  the  general  improvement  when  the 
extrapelvic  and  systemic  disorders  mentioned  in  the  precedmg  para- 
graph have  been  relieved. 

Vaccines  and  Serum  Therapy. — There  is  a  strong  hope  that  in  the  near 
future  definite  result.^  will  be  obtained  by  vaccines  or  serum  therapy 
and  that  by  such  means  we  may  have  scientific  and  satisfactory  re- 
sources in  place  of  the  unscientific  and  unsatisfactory  empiricisms 
of  the  past.  Already  encouraging  results  are  being  reported.  The 
subject  although  still  in  the  formative  stage  has  been  developed  already 
to  the  point  of  tentative  application.  Autogenous  vaccines,  that  is, 
those  derived  from  the  bacteria  of  the  patient,  appear  to  be  much  more 
reliable  and  effective  than  heterogenous  vaccines  which  are  derived 
from  the  bacteria  of  other  persons.  Results  from  vaccines  in  gono  -rhoeal 
infection  of  mucous  membranes  have  been  discouraging. 

The  Kidneys  should  be  made  to  eliminate  their  proper  amount  of 
urea  and  other  solids.  A  quantitative  urinalysis  should  be  made  to 
estimate  the  total  solids  excreted  in  twenty-four  hours;  and  if  there  is 
deficient  elimination  the  granular  efi'ervescing  sodium  phosphate  in 
copious  draughts  of  pure  water  or  mineral  water  or  pure  water  alone  is 
indicated;  the  diet  should  include  less  animal  and  more  vegetable  food. 

Ansemia,  notably  the  anaemia  of  fat  flabby  women,  often  is  associated 
with  local  engorgement,  especially  in  the  uterus.  In  such  cases  local 
treatment  is  useless.  Iron,  arsenic,  manganese,  the  bitter  tonics, 
mineral  waters,  nutritious  food,  adequate  exercise,  and  regular  habits 
are  essential. 

Constipation  is  associated  almost  constantly  with  uterine  catarrh. 
Large  accumulations  of  old,  hard  fecal  matter  may  displace  the  uterus 
and  other  pelvic  organs,  and  by  their  mechanical  eft'ects  may  keep  up 
constant  engorgement.  Successful  treatment  of  constipation,  which 
should  be  rather  regulative  than  medicinal,  therefore  forms  an  essential 
part  of  the  therapy  of  endometritis.  Polypharmacy  is  to  be  avoided. 
Strong  laxatives  tend  to  congest  the  abdominal  and  pelvic  organs — 


238     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

the  very  condition  we  want  to  relieve — and  should  therefore  be  avoided. 
The  more  positive  cathartics,  like  aloin  or  podophyllin  at  bedtime, 
which  usually  act  strongly  the  next  morning,  are  objectionable,  and  such 
drugs  if  given  at  all  should  be  in  small  divided  doses  combined  with 
iron  and  nux  vomica,  and  given  at  least  three  times  a  day.  The  cathartic 
dose  should  be  diminished  each  time  the  prescription  is  renewed  until 
only  the  tonic  remains. 

Hygienic  measures  alone  may  be  adequate.  These  include  properly 
selected  diet,  regularity  in  exercise,  and  especially  regularity  in  going 
to  stool.  Massage  is  a  measure  valuable  for  its  direct  influence  on 
the  action  of  the  bowels  and  on  the  general  circulation.  Mineral 
waters,  magnesium  sulphate,  magnesium  citrate,  lithium  citrate, 
sodium  phosphate,  and  Carlsbad  salt  are  useful,  and  are  given  best 
in  copious  draughts  upon  rising  in  the  morning.  x\  large  draught  of 
cold  water  at  the  same  hour  will  often  cause  free  action  of  the  bowels. 
Cascara  sagrada  is  perhaps  the  most  satisfactory  and  generally  employed 
single  cathartic. 

Tablet  triturates  of  calomel  long  continued  in  small  doses — one- 
thirtieth  to  one-tenth  of  a  grain — three  times  a  day  may  fulfil  clear 
indications;  it  stimulates  the  biliary  secretion,  renders  the  glandular 
organs  more  active,  dislodges  morbid  accumulations,  and  tends  to 
secure  proper  elimination  through  the  bowels  and  kidneys.  The 
bichloride  of  mercury  in  minute  doses — one  one-hundredth  of  a  grain — 
may  be  equally  useful.  In  the  continued  employment  of  mercurials 
it  is  well  to  secure  normal  freedom  of  the  bowels,  if  necessary,  by  the 
judicious  use  of  salines. 

Stypticin,  two  grains  four  to  six  times  a  day  in  capsules,  may  be  given 
advantageously  either  alone  or  combined  with  ergot  and  suprarenal 
extract  for  the  uterine  hemorrhage  of  hemorrhagic  endometritis. 

Colonic  flushings  of  normal  salt  solution  are  most  useful,  especially 
in  the  treatment  of  obstinate  constipation.  They  should  be  given 
with  the  patient  in  the  left  lateroprone  position  of  Sims.  To  be  most 
effective  they  must  be  copious,  slowly  given,  and  retained  for  at  least 
several  minutes.  Endometritis,  obstinate  in  young  women  and  espe- 
cially in  corpulent  young  women,  resists  treatment  unless  nutrition  be 
improved  and  weight  reduced. 

In  addition  to  the  above  measures,  tonics  and  stomachics,  such  as 
nux  vomica,  hydrochloric  acid,  and  compound  tincture  of  gentian,  are 
particularly  indicated  for  the  spastic  type  of  constipation.  The  atonic 
type  will  require  also  some  adequate  means  to  increase  intestinal  irri- 
tation. For  this  purpose  a  diet  of  the  coarser  cereals  may  be  supple- 
mented by  some  appropriate  gelatin  preparation,  such  as  agar-agar, 
which  increases  peristalsis  by  mechanical  stimulation  or  the.  muscular 
wall  of  the  bowels. 

General  Hygiene. — Dress,  exercise,  food,  sexual  relations,  care  at 
menstruation,  local  and  general  bathing  are  very  important.  A  com- 
prehensive grasp  of  the  subject  involves  the  whole  field  of  general 
medicine. 


(  IIROMC   ESDo.METiariS  230 

'1.  Topical  Treatment.  Tdpical  trratmcnt  lias  Inrii  as  much  oxer- 
estiiiKit(.'(l  as  systemic  treatment  has  been  neglected.  Once  ehniinate 
the  cases  described  in  the  forej^oing  parajjraphs  wiiich  recjuire  not  so 
much  h)cal  as  systemic  treatment  and  the  rehitively  small  remainder 
will  he  made  up  mostly  of  clearly  infectious  cases.  The  number  of  such 
ca.ses  definitely  cured  by  tojjical  aj)i)lications,  when  comj)ared  w  ith  the 
^reat  number  treated,  is  insi<;niHcant.  In  making'  such  comparison  wc 
n)ust  exclude  those  which  needed  only  systemic  treatment,  and  have 
been  relieved  by  it,  notwithstandiiiu  the  associated  topical  treatment 
which  they  did  not  need. 

The  endometriimi  has  been  the  object  of  a  vast  amount  of  >ome- 
times  mild,  many  times  useless  or  destructive  topical  treatment.  Other 
organs,  the  nose,  stomach,  intestine,  bladder,  and  eye,  are  subject  to 
the  same  catarrhal  conditions  from  the  same  fjeneral  causes.  Con- 
sistency therefore  might  indicate  topical  treatment  for  them  also. 
If  in  a  given  case,  for  example,  the  whole  intestinal  canal  and  bladder 
and  endometrium  were  catarrhal,  it  might  be  quite  as  reasonable  to 
apply  destructive  agents  to  all  as  to  one.  Such  an  experiment  would 
not  only  show  that  the  human  uterus  has  endured  an  immense  amount 
of  abuse,  but  would  demonstrate  successfully  the  absurdity  of  topical 
treatment  applied  to  a  mucous  membrane  when  the  discharge  is  only 
one  of  many  local  evidences  of  a  general  condition.  Very  significant 
is  the  fact  that  often-repeated  handling  of  the  genitals  may  establish 
the  habit  of  local  treatment,  may  even  give  rise  to  psychic  irritation 
or  depression  or  monomania  on  that  subject. 

Intra-uterine  treatment  as  ordinarily  practised  is  tedious,  and 
whether  mild  or  severe,  if  frequently  repeated  with  indifferent  aseptic 
care,  may  set  up  new  infection,  or  may  carry  the  old  infection  to  deeper 
structures.  Many  cases  which  do  well  on  mild  topical  treatment 
would  do  better  on  systemic  treatment  alone. 

Strong  caustic  intra-uterine  applications,  including  electricity,  which 
have  the  power  to  destroy  the  diseased  structures  sometimes  will 
arrest  purulent  endometritis,  but  in  doing  this  they  may  destroy  the 
endometrium,  injure  the  myometrium,  and  reduce  the  uterus  to  a 
cirrhotic-like,  cicatricial  condition.  Numerous  plastic  operations  have 
been  devised  with  but  little  success  to  reopen  the  uterine  canal  thus 
constricted.  The  endometrium  now  has  lost  permanently  its  epithelial 
covering,  the  chief  protection  of  the  uterus  against  microbic  invasion. 

I  have  tested  carefully  the  routine  use  of  topical  applications,  the 
vaginal  douche,  the  swabbing  out  of  the  uterus  with  cotton,  the  in- 
jection of  astringents,  the  vaginal  and  intra-uterine  application  of  dry 
powders,  intra-uterine  pencils  of  various  alterative  and  caustic  sub- 
stances, wool-glycerin  tamponade,  electricity,  and  intra-uterine  gauze 
tamponade,  and  the  patient  use  of  such  means  has  been  followed  by  a 
few  cures  and  by  much  disappointment,  to  say  nothing  of  some  positive 
harm.  Topical  treatment  should  not  at  any  rate  be  continued  beyond 
a  few  weeks  imless  good  results  have  become  apparent.  It  has  a  more 
legitimate  place  as  a  supplement  than  as  a  substitute  for  systemic  and 


240      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

operative  treatment.  A  reproach  will  be  lifted  from  the  medical  pro- 
fession when  the  indiscriminate  use  of  topical  treatment  has  been  relegated 
to  the  dark  ages  of  gynecology. 

If  topical  treatment  is  to  be  used,  especially  if  it  is  to  be  intra-uterine 
— see  Chapters  II.  and  IV. — the  cervix  should  be  exposed  with  Sims' 
speculum,  the  vagina  cleansed  thoroughly  with  dry  absorbent  cotton 
on  dressing-forceps.  Slight  traction  is  now  made  on  the  cervix  by 
tenacula  or  blunt-tooth  forceps,  to  straighten  the  uterine  canal,  and  the 
endometrium  is  cleansed  by  means  of  cotton  wound  on  an  applicator. 


FiGUBE    113 


Patient  in  dorsal  position.  Cervix  exposed  by  perineal  retractor  m  right  hand  of  nurse.  Uterus 
drawn  down  with  tenaculum  in  left  hand  of  operator.  Any  desired  fluid  may  be  injected  into  endo- 
metrium by  means  of  special  cannula  attached  to  syringe.  This  syringe,  worked  by  right  hand  of 
operator,  is  shown  in  the  upper  left-hand  corner.  Cannula  here  is  shown  as  detached  frorn  the  syringe. 
Outflow  of  injected  fluid  is  secured  bv  a  wire  attachment  running  parallel  to  the  cannula  and  a  little 
below  it.  Sims'  speculum  and  the  left  lateroprone  position  would  be  preferable  to  the  Simon  speculum 
and  the  dorsal  position. 

The  cervical  plug  of  mucus,  if  present,  should  be  removed.  The  desired 
application  may  then  be  carried  into  the  endometrium  by  means  of  the 
applicator  wound  with  fresh  absorbent  cotton,  or,  if  the  canal  be  very 
open,  by  means  of  fine  dressing-forceps.  A  pledget  of  cotton  saturated 
with  glycerin  or  a  10  per  cent,  mixture  of  ammoniated  ichthyol  and 
glycerin  may  be  placed  on  the  vagina  as  a  protective  and  for  its  hygro- 
scopic effect.  Over  this  place  a  pledget  of  dry  cotton,  to  keep  the 
first  in  position  and  to  absorb  moisture.  The  vaginal  tampon  should 
be  removed  in  twenty-four  hours.    Intra-uterine  cleanliness  is  the  first 


CHROXIC  ENDOMETRITIS  241 

requisite.  To  set-urc  tliis,  an  open  canal  and  normal  (iraiiiage  are 
essential.     During  such  treatment  coitus  is  prohibited. 

It  wouKl  be  confusing,  and  it  is  unnecessary  to  name  tlie  innumerable 
drugs  and  chemicals  which  arc  lauded  for  intra-uterine  medication. 
In  cases  of  purulent  endometritis,  one  may  make  ad^■antageously 
a  single  application  of  40  per  cent,  formalin  to  the  endometrium,  and 
in  some  very  intractable  cases  may  repeat  this  once  or  twice  at  inter- 
vals of  a  month.  This  application  is  made  best  by  means  of  a  uterine 
applicator  wound  with  cotton,  the  vagina  being  protected  by  a  wad  of 
cotton  placed  behind  the  cervix  uteri.     Figure  US. 

More  conservative  and  perhaps  more  elective  than  formalin  is  the 
intra-uterine  injection  of  tincture  of  iodine,  which  is  particularly  appli- 
cable to  hemorrhagic  endometritis  in  a  large,  spongy,  flabby  uterus;  it 
is  not  a})j)roved  in  other  cases.  One  drachm  or  less  should  be  injected 
at  each  treatment.  In  order  to  prevent  the  tincture  from  being  forced 
through  the  Fallopian  tubes,  it  should  be  thrown  in  gently  and  allowed 
to  run  out ;  the  injection  may  be  repeated  twice  a  week;  if  in  two  months 
there  is  not  marked  improvement,  the  treatment  should  be  interrupted 
and  if  necessary  resumed  after  curettage.  The  technique  of  injecting 
the  uterus  is  shown  in  Figure  113.  In  place  of  the  instruments  here 
presented  an  ordinary  small  glass  female  catheter  attached  to  a  com- 
mon ear  syringe  by  means  of  a  short  rubber  tube  may  be  used. 
Attention  is  especially  directed  to  the  combined  use  of  tents  and 
iodine  in  Chapter  V. 

The  Biers  cupping  treatment,  mentioned  at  the  end  of  Chapter 
IV.,  is  important  in  connection  with  cleansing  the  endometrium,  both 
as  an  independent  remedial  measure  and  as  a  preparation  for  intra- 
uterine treatment. 

3.  Surgical  Treatment. — ^Yhen  the  endometritis  is  distinctly  infec- 
tious and  chronic,  both  topical  and  systemic  treatment  are  usually 
inadeciuate,  although  either  properly  may  supplement  surgical  meas- 
ures. The  disease  of  the  mucosa  then  may  be  removed  by  the  sharp 
oirette.  The  operation  is  rendered  extra-hazardous  by  active  inflam- 
mation in  the  Fallopian  tubes  or  by  any  other  active  pelvic  inflamma- 
tion which  renders  the  uterus  immobile  or  very  sensitive  to  the  touch. 

In  hyper  plastic  endometritis,  particularly  the  polypoid  variety  already 
described,  curettage  is  not  only  relatively  safe  and  efficient  but  may 
be  necessitated  for  purposes  of  differential  diagnosis  between  endo- 
metritis and  malignant  disease.  The  indication  for  such  diagnostic 
curettage  is  uterine  hemorrhage  which  if  it  be  consequent  upon  endo- 
metritis, the  operation  will  arrest,  and  if  due  to  malignant  disease,  will 
open  the  way  to  early  diagnosis  and  radical  surgical  treatment. 

Technique  of  Curettage. — The  accompanying  series  of  illustrations. 
Figures  114  to  US,  shows  the  steps  of  the  operation  of  sharp  curettage. 
The  dilatation  should  be  begun  with  a  small  light  dilator.  Figure  114, 
and  continued  with  a  larger  dilator  of  the  Wathen  type,  Figure  115. 
This  instrument  is  of  heavy  construction  and  the  blades  of  it  ha^■e 
great  expanding  power.  After  the  uterus  has  been  dilated  to  the  extent 
16 


242      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

of  one-half  to  three-quarters  of  an  inch  the  endometrium  is  subjected 
to  sharp  curettage,  as  shown  in  Figure  116.  In  curettage  of  the  uterus 
the  perineal  retractor  may  to  advantage  give  place  to  the  index  and 
middle  fingers  of  the  left  hand,  while  the  operation  is  performed  by 
means  of  the  curette  in  the  right  hand.  After  curettage  the  uterus 
is  flushed  out  with  sterile  water.  Figure  117.  The  cannula  used  for  this 
purpose  may  be  a  simple  glass  female  catheter  attached  to  a  rubber 
tube.  This  tube  leads  from  a  funnel  held  by  a  nurse  above  the  patient. 
The  water  flows  from  the  funnel  through  the  tube  and  the  glans 
cannula  into  the  uterus  until  the  endometrium  is  irrigated  thoroughly. 

Figure  114 


Curettage.  First  step:  dorsal  position.  Cervix  exposed  by  perineal  retractor  in  right  hand  of 
nurse.  Uterus  drawn  down  by  vulsellum  forceps  in  left  hand  of  assistant.  Dilatation  begun  by  small 
dilator  in  right  hand  of  operator. 

During  the  irrigation  the  cannula  should  continually  be  withdrawn 
and  reintroduced,  in  order  to  prevent  the  possible  forcing  of  the 
injected  fluid  into  the  Fallopian  tubes.  Observe  the  forceps  fastened 
to  the  rubber  tube.  This  is  a  practical  device  for  reducing  the  size 
of  the  rubber  tube  so  that  it  will  fit  a  cannula  or  catheter  of  smaller 
size.  Not  infrequently  this  difference  in  caliber  between  the  tube  and 
cannula  gives  rise  to  considerable  annoyance  during  an  operation, 
which  may  be  obviated  much  more  readily  and  quickly  by  means  of 
the  forceps  thus  used  than  by  the  common  means  of  tying  a  strong 


ClUx'OXIC  ENDOMETRITIS 


243 


Kkjiiik    I  I 


Curettage.  ISccnnd  step:  dorsal  position.  Cervix  exposed  by  perineal  retractor  in  right  hand  of 
nur.se.  Uterus  drawn  down  by  vuLsellum  forceps  in  left  hand  of  assistant.  Dilatation  completed  by 
Wathen  dilator  in  hands  of  operator. 


Figure   116 


Cnrettape.  Third  step:  dorsal  position.  Perineum  retracted  bv  two  fingers  of  operator's  left 
hand.  I  terns  drawn  down  by  viilsplhim  forceps  in  left  hand  of  assistant.  Endometrium  curetted 
by  sharp  curette  in  operator's  right  hand. 


244      INFECTIONS,    INFLAMMATIONS,   AND   ALLIED   DISORDERS 

cord  tightly  around  the  end  of  the  tube  at  the  point  where  it  receives 
the  cannula. 

In  place  of  the  funnel  a  thoroughly  sterile  fountain-syringe  may  be 
used.  The  rubber  douche-bag  or  the  fountain-syringe  is  hung  usually 
on  a  hook  or  nail  at  some  point  near  to  and  above  the  patient.  Some- 
times, however,  in  private  p^acti^•e  the  operation  is  delayed  because 
nothing  is  available  upon  which  to  hang  the  douche-bag.  To  OA'er- 
come  this  difhculty  the  bag  may  be  suspended  by  two  pairs  of  pressure- 
forceps,  as  shown  in  A  and  B,  Figure  117,  the  upper  forceps  being 


Figure   1 1 1 


Curettage.  Fourth  step:  dorsal  position.  Perineum  retracted  by  two  fingers  of  operator's  left 
hand.  Uterus  drawn  down  by  vulsellum  forceps  in  left  hand  of  assistant.  Endometrium_  irrigated 
by  cannula  inserted  into  rubber  tube  in  operator's  right  hand.  Figures  A  and  B  show  a  fountain  syringe 
attached  to  a  tov,-el  by  means  of  pressure-forceps.  The  towel  may  be  fastened  to  a  curtain  or  other 
hanging  by  means  of  safety-pins.     The  fountain-syringe  may  be  used  instead  of  the  funnel. 

fastened  to  some  fabric  and  the  lower  forceps  to  the  douche-bag.  A 
shows  the  forceps  and  douche-bag  entire;  B  shows  the  forceps  and  upper 
part  of  the  douche-bag  more  in  detail.  The  operation  is  performed 
usually  in  front  of  a  window.  Therefore,  in  a  private  house  the  curtain 
may  be  used  upon  which  to  fasten  with  safety-pins  a  clean  towel  or 
sheet  to  which  the  upper  forceps  may  be  attached.  The.  opening  of 
the  bag  should  be  closed  with  a  plug  of  absorbent  cotton. 

The  irrigation  having  been  completed,  the  fingers  of  the  operator 
are  removed  from  the  vagina,  and  the  perineum  again  is  retracted  by 
means  of  the  Simon  speculum  in  the  hand  of  the  nurse  or  assistant. 
In  order  to  prevent  the  application  from  coming  in  contact  with  the 


Cllh'O.MC    EMXtMKTh'ITIS 


245 


^■;ll;iIlil,  it  is  WH'll.as  shown  in  l-'i^iirc  I  is,  to  protect  tlic  \  iiiiiuil  iiiiicosa 
with  a  i)l(.'(lji;ot  of  cotton  phiccd  between  the  posterior  wall  of  the  cervix 
and  the  jKTineal  retractor.  Before  niakin<i;  the  application  two  forceps 
or  applicators  should  l-e  wound  with  al)sorl)ent  cotton,  and  one  should 
l)e  ])ushed  into  the  uterine  canal  with  the  cotton  dry  in  order  to  absorb 
any  Hiiid  whic-h  may  remain  after  the  irriiiation,  and  to  prevent  oozing, 
for  if  the  application  be  made  in  a  uterus  filled  with  blood  it  may  be 
made  to  the  blood  and  not  to  the  mucosa.  The  cotton  on  the  other 
forceps   should   now   be   dipped    in   the   desired   disinfectant — usually 


FiriruK   lis 


Curettage.  Final  step:  dorsal  position.  Perineum  retracted  by  a  Simon  retractor  in  right  hand  of 
nurse.  Uterus  drawn  down  by  vulsellum  forceps  in  left  hand  of  assistant.  Endometrium  disinfected 
by  cotton  wound  on  Emmet's  dressing  forceps  and  saturated  with  desired  disinfectant.  Application 
made  by  right  hand  of  operator. 


tincture  of  iodine — and  introduced  just  as  the  first  is  withdrawn.  No 
dressing  is  required.  A  vaginal  douche  containing  0.5  per  cent,  lysol 
should  be  given  twice  daily  for  a  period  of  two  weeks.  This  and  regu- 
lation of  the  bowels  are  the  only  special  after-treatment. 

The  treatment  of  endometritis,  even  with  the  curette,  is  not  uni- 
formly successful.  Dilated  and  obstructed  blood-vessels  cannot  always 
be  restored  to  their  proper  caliber.  Disorganized  lymphatics,  nerves, 
and  glands  do  not  always  resume  their  normal  functions.  Regenera- 
tion of  lost  structures  is  not  always  possible.    In  these  respects  endome- 


246      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

tritis  offers  a  close  analogy  to  nasal  catarrh.  In  the  glandular  forms 
of  the  disease,  in  which  the  endometrium  yet  retains  sufficient  integrity 
to  insure  regeneration  of  the  glandular  and  epithelial  structures,  the 
sharp  curette  offers  a  possible  symptomatic  and  histological  cure. 

Indications  for  Hysterectomy. — When  the  disease  has  progressed  to 
the  atrophic  stage  of  interstitial  endometritis  and  the  endometrium  is 
destroyed  physiologically  and  only  a  degree  of  symptomatic  cure  is 
possible,  and  when  endometritis  is  complicated  with  extensive  chronic 
metritis  and  obstinate  pelvic  infection  and  the  uterine  discharge  will 
persist  regardless  of  curettage  or  of  any  other  intra-uterine  treatment, 
the  uterus  being  like  the  wall  of  an  abscess  cavity,  hysterectomy  may 
be  the  only  means  of  relief.  Since  this  extreme  measure  may  be  indi- 
cated also  for  extra-uterine  inflammation,  the  consideration  of  it  is 
referred  to.  the  subject  of  Inflammation  of  the  Uterine  Appendages. 

Regeneration  of  Endometrium  after  Curettage. — Recent  investigations 
of  Werth  and  others  prove  that  prompt  regeneration  of  the  uterine 
mucosa  may  follow  sharp  curettage.  Studies  of  the  recently  curetted 
endometrium  show  that  the  work  often  is  done  imperfectly,  and  that 
large  portions  of  the  diseased  mucosa,  particularly  in  the  cornua  and 
lateral  walls,  are  apparently  inaccessible  to  the  ordinary  curette.  Special 
small  curettes  should  be  used  therefore  for  these  parts. 

Werth  reports  histological  examinations  of  six  uteri  removed  at 
periods  varying  from  three  to  sixteen  days  after  curettage.  All  cases 
showed  unequal  results  of  the  scraping  on  the  various  parts  of  the 
uterine  mucosa.  Some  parts  were  untouched.  In  some  the  super- 
ficial layers  had  been  removed  and  the  deeper  layers  left,  and  in  other 
parts  the  muscularis  had  been  attacked.  The  mucosa  in  the  fundus 
and  in  the  lateral  portions  of  the  cavity  most  frequently  was  left 
intact.  The  abrasions  on  the  anterior  wall  w^ere  deeper  than  on  the 
posterior.  They  were  also  deeper  in  the  lower  part  of  the  corpus  near 
the  internal  os.  This  is  explained  by  the  convergence  of  the  down- 
ward strokes  of  the  curette.  Except  in  places  in  which  the  muscularis 
had  been  injured  by  the  curette,  the  entire  lining  of  the  uterus  was 
covered  with  new  mucosa,  the  glands  opening  freely  on  a  surface  of 
unbroken  superficial  epithelium.  The  regenerating  tissue  was  supplied 
with  new  blood-vessels  which  grew  out  of  the  muscularis  or  out  of  the 
remaining  mucosa.  The  vessels  were  surrounded  with  a  broad  mantle 
of  fibrillary  connective  tissue  which  followed  their  ramifications  almost 
to  the  surface  of  the  mucosa. 

The  glands  were  regenerated  from  their  deeper  portions  which  the 
curette  had  spared,  especially  from  those  which  were  situated  where 
the  mucosa  dips  deep  down  into  the  muscularis;  they  grew  out  toward 
the  surface  together  with  the  surrounding  blood-vessels  and  fibrillary 
connective  tissue.  The  surrounding  stroma  was  observed  frequently 
to  grow  more  rapidly  than  the  glands,  and  to  give  a  somewhat  irreg- 
ular, jagged  contour  to  the  regenerated  endometrium.  The  superficial 
epithelium  w^as  found  to  be  regenerated  principally  from  that  of  the 
glands.    In  some  places  the  young  epithelial  cells  were  found  flattened 


CHRONK     KXDOMETRITIS  '  247 

and  enlarged.  In  tho  later  stages  of  the  regeneration  of  the  mucosa 
the  excess  of  fibriUary  connective  tissue  was  observed  to  disappear 
by  iiyaline  degeneration.  This  process  on  the  fifth  da\'  after  curettage 
was  visible  in  the  subepithelial  layers;  and  on  the  tenth  day  only  a 
few  fibrilhe  were  left  in  the  superficial  stroma;  in  their  places  were  large, 
spintUe-sliaped  cells,  with  several  processes  of  protoplasm.  Only  in 
those  parts  where  the  muscularis  had  been  abraded  did  there  exist 
a  condition  resembling  that  of  granulation-tissue.  These  observations 
of  Werth  go  to  show  that  the  sharp  curette  in  efficient  conservative 
hands  is  less  objectionable  notwithstanding  its  destructive  effects 
than  was  supposed  formerly.  This  fact  taken  in  connection  with  the 
sometime  meddlesome  inefficiency  and  danger  of  the  dull  curette 
speaks  by  comparison  for  the  sharp  instrument,  provided  the  operation 
is  indicated  and  performed  by  a  skilful  hand. 


CHAPTER    XVII 
CHRONIC  METRITIS 

Chronic  metritis — usually  understood  to  mean  inflammation  of 
the  uterine  muscularis,  a  condition  more  accurately  described  by  the 
word  myometritis — is  taken  here  in  its  broader  literal  sense,  and  is 
used  to  designate  chronic  inflammation  of  the  uterus  as  a  whole,  and 
to  include  therefore  endocervicitis,  endometritis,  myometritis,  and 
perimetritis.  The  various  parts  of  the  uterus — i.  e.,  the  endometrium, 
myometrium,  perimetrium,  corpus,  and  cervix — never  are  involved  in 
sharply  defined  areas  of  disease,  although  any  one  of  them  may  be  the 
specially  affected  part  of  the  diseased  organ.  The  disease  is  commonly 
the  consequence  of  endometritis  and  coincident  with  it.  Infection  of 
the  uterus  as  observed  by  the  clinician,  except  acute  gonorrhoeal  and 
puerperal  metritis,  is  generally  chronic. 

The  striking  phenomena  of  acute  metritis  are  the  active  infective 
and  inflammatory  processes.  The  term  chronic  metritis  stands  not  so 
much  for  definite  processes  as  for  certain  chronic  organic  changes, 
in  the  quantity  and  quality  of  the  glandular  elements,  muscularis, 
blood-vessels,  lymphatics,  and  connective  tissue.  These  changes  are 
usually  hypertrophic,  hyperplastic,  or  atrophic.  They  have  been  the 
subject  of  a  long  and  unsatisfactory  discussion,  and  have  been  designated 
variously  as  infective,  inflammatory,  irritative,  subinflammatory, 
and  congestive.  Although  the  changes  under  consideration  may  not 
always  conform  to  the  strict  idea  of  inflammation,  there  is  yet  a  pro- 
priety in  calling  them  inflammatory,  because  the  essential  element  of 
inflammation — round-cell  infiltration — is  usually  present.  In  chronic 
inflammations  migration  of  these  cells  occurs,  if  at  all,  to  a  less  degree 
than  in  acute  inflammation. 

Etiology  of  Chronic  Metritis 

The  chief  modes  of  infection  are  unclean  examinations,  local  treat- 
ments, operations,  and  excessive  venery. 

Predisposing  Causes. — The  local  'predisposing  causes  are  as  follows: 
parturition  and  abortion;  menstrual  congestion  and  other  congestions 
due  to  the  mechanical  irritation  of  tumors,  displacements,  stenoses, 
pessaries,  and  other  foreign  bodies. 

The  general  predisposing  causes  are  as  follows:  chronic  diseases  of 
the  heart,  lungs,  liver,  and  kidneys,  which  may  give  rise  to  passive 
congestion  in  the  reproductive  organs;  nutritional  disorders  associated 
with  faulty  metabolism,  among  which  may  be  mentioned  diabetes, 
rheumatism,  and  gout. 
( 248 ) 


CllliOXIC   MKTh'ITI.^  249 

Exciting  Causes. — 'Hu-  Imcteriolo^ical  rxcitinj,^  cjiiises  have  heen  set 

forth  ahrady  in  the  forcuoini;  cliajjttTs. 

Pathology  of  Chronic  Metritis 

Since  cliroiiic  metritis  is  the  sum  of  all  the  inflammations  of  the 
uterine  mucosa,  uterine  muscularis,  and  uterine  jK'ritoneiini,  it  follows 
th.at  the  patholo^^y  of  it  must  embrace: 

I.  Chronic  chano;es  in  the  mucosa — endometritis  and  endocer- 
vicitis — of  which  the  patholo<i:\'  has  been  flescribed  in  Chapter  X\'. 
and  XVI. 

II.  Chronic  changes  in  the  perimetrium — peritonitis — which  will  be 
described  in  the  chapter  on   PeKic  Peritonitis. 

III.  Chronic  changes  in  the  muscularis  which  occur  in  two  forms: 

1 .  Hypertrophic. 

2.  Interstitial. 

1.  Pathology  of  Hypertrophic  Metritis. — In  this  form  of  chronic 
metritis  all  the  histological  elements  are  increased.  Hypertrophy  of 
puerperal  origin  should  be  distinguished  from  that  of  non-puerperal 
origin. 

Puerperal  Hypertrophy,  commonly  known  as  subin\olution  which  may 
be  defined  as  the  failure  of  the  physiological  hypertrophy  of  preg- 
nancy to  subside  after  labor,  takes  place  as  follows:  the  muscular 
elements,  coimective  tissue,  lymph-  and  blood-vessels,  enormously 
increased  during  the  evolution  of  pregnancy,  fail  to  undergo  normal 
physiological  degeneration  and  absorption  after  labor;  notably  the 
lymph-  and  blood-vessels  continue  large,  full,  and  stagnant,  which 
partly  explains  the  congestion  and  infiltration  of  the  greatly  thickened 
uterine  walls.  The  uterus  may  be  more  than  twice  as  large  as  normal; 
the  enlargement,  however,  is  not  always  uniform,  but  may  pertain 
especially  to  the  cervix  and  corpus  uteri.  The  softness  and  mobility 
of  the  organ  accounts  readily  for  the  fact  that  many  uterine  flexures 
date  from  the  puerperium. 

Non-puerperal  Hypertrophy  is  pathological  from  the  beginning,  and 
may  occur  in  women  who  have  never  been  pregnant.  Clinically  it  is 
sometimes  impossible  to  distinguish  between  the  puerperal  and  ni^n- 
puerperal  varieties. 

Great  hypertrophic  elongation  of  the  supravaginal  and  enlarge- 
ment of  the  infravaginal  portions  of  the  cervix,  with  descent,  are 
described  in  the  chapters  on  Laceration  of  the  Cervix  and  I^isplace- 
ments.  Sometimes  h^-pertrophic  enlargement  pertains  chiefly  to  the 
corpus  uteri,  sometimes  to  the  cervix;  or  it  may  involve  uniformly 
the  entire  organ.  Hypertrophy  of  the  cervix  often  is  confounded  with 
laceration.  The  symptoms,  like  the  causes,  are  almost  identical  with 
those  of  the  associated  endometritis.  In  the  absence  of  marked  peri- 
metritis, or  parametritis,  the  uterus  is  not  very  sensitive  to  the  touch. 
Downward  displacement  from  increased  weight  is  usual.  Perverted 
menstrual  and  other  functions  r.re  the  same  as  in  endometritis. 


250      INFECTIONS,   INFLAMMATIONS.   AND  ALLIED  DISORDERS 

The  prognosis  is  much  more  favorable  for  puerperal  than  for  non- 
puerperal myometritis — i.  e.,  subinvolution,  if  non-infectious,  is  often 
only  temporary.  The  disease  is  apt  to  be  obstinate  and  destructive 
in  proportion  as  the  infectious  element  predominates. 

2.  Pathology  of  Interstitial  or  Cirrhotic  Metritis.— In  this  form 
of  metritis,  sometimes  called  areolar  hyperxdasia,  there  are  increase 
of  connective  and  loss  of  muscular  tissue.  The  muscular  wall  is  pale 
and  indurated.  The  microscope  will  show  hyperplasia  of  intermus- 
cular connective  tissue,  corresponding  atrophy  of  muscle-fibers,  and 

Figure  119 


So-called  hypertrophic  elongation  of  the  supravaginal  portion  of  the  cervix — rare  except  as  a  post- 
operative or  postmortem  condition.  The  cervix  often  becomea  elongated  by  traction  during  the 
removal  of  the  uterus. 


contraction  of  blood-vessels  as  already  stated.  The  chronic  changes 
in  these  various  parts  may  be  the  outcome  of  acute  processes  already 
described  under  acute  metritis,  and  this  is  particularly  true  of  the 
gonorrhoeal  variety,  or  there  may  have  been  no  clearly  marked  acute 
stage — i.  e.,  the  disease,  at  least  apparently,  may  have  been  chronic  or 
subacute  from  the  beginning. 

Hyperplasia  of  connective  tissue,  whether  puerperal  or  non-puerperal, 
may  follow  hypertrophy  or  may  develop  independently  of  it.  This 
form  of  the  disease  often  results  in  a  sort  of  pathological  involution, 
with  the  following  permanent  changes:  The  lymph- vessels  and  blood- 


CIIUOMC   MET  HIT  IS 


251 


vessels  shrink  and  wither,  llu-  mitritioii  ot'  the  nnixiihir  ch-nients  is  cut 
off,  and  they  disappear  as  if  crowded  out  hy  the  increasing  connective 
tissue;  the  uterus  now  l)ecomes  hard  and  ana-^mic;  it  still  may  remain 
larjre  from  the  superabundant  connective  tissue,  but  finally  this  may 
contract  and,  cicatrix-like,  reduce  the  orjian  even  below  its  normal  size. 
The  result  of  these  chan^'es  are  great  uterine  irritation  and  pelvic  pain 
The  whole  organ  with  its  appendages  and  adjacent  structures  is  in  a 
state  of  permanent  malnutrition. 

In  connection  with  the  atrophic  changes  of  interstitial  and  cirrhotic 
metritis  may  be  mentioned  two  special  forms  of  atrophy:  I,  puerperal 
atrophy — superinvolution.  II,  a  certain  form  of  non-puerpjeral  atrophy 
and  arteriosclerosis. 


H\-pertrophy  of  the.cennx  uteri.    The  expansion  of  the  cer\-ix  is  due  partly  to  aversion  of  intra-uterine 
muposa  consequent  on  laceration  of  the  cen'ix. 

Puerperal  Atrophy — superinvolution — is  the  direct  opposite  of  sub- 
involution. In  superinvolution  the  process  of  degeneration  and  ab- 
sorption after  labor  passes  beyond  the  physiological  limits,  and  the 
uterus  shrinks  below  the  normal  size  and  becomes  soft  and  excessively 
mobile.  The  condition  resembles  senile  atrophy  of  the  menopause. 
Apparently  there  are  two  distinct  varieties  of  superinvolution — one 
temporary,  the  other  permanent.  The  two  forms  are  differentiated 
by  the  fact  of  a  non-septic  puerperium,  usually  with  prolonged  lactation, 
in  the  temporary  form,  which  is  not  infectious,  and  by  the  history  of  a 
septic  puerperium  in  the  permanent  variety,  which  is  infectious.     In 


252      INFECTIONS,    INFLAMMATIONS,    AND   ALLIED   DISORDERS 

the  latter  case  one  or  more  of  the  reproductive  organs  or  parts  thereof 
— i.  e.,  the  endometrium,  myometrium,  and  the  uterine  appendages — 
become  infected  and  in  a  physiological  sense  destroyed.  In  the  tem- 
porary variety  spontaneous  recovery  may  occur  and  the  woman  again 
may  bear  children.  In  the  destructive  form  there  is  permanent  atrophy 
of  all  the  structures  involved.  Menstruation,  if  it  returns  at  all,  is 
scanty  and  generally  painful.  Immediate  amenorrhoea  is  the  rule. 
There  is  sometimes  a  painful  molimen  in  place  of  menstruation. 

Figure  121 


Hypertrophy  of  the  corpus  uteri:    observe  the  great  size  of  the  corpus  relative  to  that  of  the  cervix. 


Non-puerperal  Atrophy. — There  is  another  class  of  cases  in  which 
atrophy  of  the  reproductive  organs  occurs  independently  of  parturition. 
This  form  of  atrophy  is  generally  the  result  of  chronic  wasting  disease, 
like  tuberculosis  and  diabetes;  or  of  acute  infectious  disease,  like 
scarlatina,  rubeola,  and  enteric  fever.  There  is  always  cessation  of 
menstruation.  This  is  a  conservative  effort  of  nature  to  save  the 
patient's  blood  and  strength.  Unfortunately,  however,  the  ill-health 
of  the  patient  often  is  attributed  wrongly  to  the  amenorrhoea,  and 
treatment  designed  to  stimulate  and  re-establish  menstruation  some- 
times is  used.  By  such  means  the  woman's  vitality  may  still  further 
be  exhausted.  The  above  facts  from  the  therapeutic  standpoint,  espe- 
cially in  tuberculous  and  other  wasting  diseases,  are  very  significant. 
Clearly  the  treatment  should  not  be  local,  but  systemic. 


PLATE    Vir 


FIGURE   1 


M 

^ 

-'■ 

a-_ 

/^^         CMF 

'"*'. 

SM- 

^-%' 

LMF 

3rr>:. 

' 

/ 

» '■ 

-     " 

SCT 

Cross-section  of  the  Normal  Fallopian  Tube  at  the  Uterine 

Ostium. 

M,   mucosa.      CMF,   circular  muscle   fibres.      LMF,    longitudinal   muscle   fibres. 
SCT,  subperitoneal  connective  tissue.      lo  diameters. 


FIGURE  2 


^^.1.-: 


^-J 


Cross-section  of  Fallopian  Tube  through  Abdominal  Ostium. 

Observe  the  high  mucous  folds  of  the  endosalpinx. 

The  walls  of  the   tube  in  both  figures   contain  numerous  bloodvessels  shown 
in  red.      lo  diameters. 


CHRONIC  METRITIS 


253 


Siiperiiivoliitioii  and  non-puerperal  atrophy  are  not  very  common; 
the  causes  are  obscure;  the  precise  relation  of  inflammation  to  them 
is  unknown.  Excej)t  in  the  temporary  non-infectious  form  alreadx- 
mentioned,   recoxcry   rarely  or  ne\-er  takes  place. 

Arteriosclerosis.  Chronic  metritis  in  ad\anced  years  is  associated 
not  uncommonix  with  sclerosis  of  the  uterine  arteries,  and  in  .some 
instances  with  calcareous  deijeneration  of  the  vessels;  these  changes 
may  be  looked  upon  as  senile  dej^eneration,  are  not  therefore  always, 
in  the  strict  sense,  pathological,  but  may  be  rather  the  natural  changes 
of  old  age. 


Symptoms  and  Diagnosis  of  Chronic  Metritis 

Physical  Signs. — On  bimanual  examination  the  uterus  appears  ab- 
normal in  size,  harder  and  firmer  than  natural,  and  in  the  later  .stages 
may  be  partially  contracted  to  rudimentary  size  by  atrophic  changes; 
tenderness  on  pressure  not  very  marked  unless  there  is  complicating 
inflammation  of  the  uterine  appendages.  Fixation  or  a  varying  degree 
of  mobility  according  to  the  degree  of  peri-uterine  infiltration  and  adhe- 
sions. Anteversion  and  some  degree  of  descent  is  a  classical  de\'ia- 
tion  of  the  chronically  inflamed  uterus.  Retroversions  and  flexions, 
however,  not  uncommonly  occur;  enlargement  or  diminution  of  the 
uterus,  which  may  be  demonstrated  by  the  passing  of  the  sound. 

Symptoms. — The  temperature  is  normal  or  only  slightly  elevated. 
Pain  is  not  acute;  there  is  usually  a  sense  of  aching,  pressure,  weight, 
and  dragging  in  the  back,  hypogastrium,  and  thighs.  ^Menstrual 
disturbances,  such  as  menorrhagia,  intermenstrual  uterine  hemorrhages, 
and  dysmenorrhoea,  singly  or  combined,  are  commonly  present.  Ster- 
ility, which  may  be  due  to  coexisting  lesions,  is  usual.  Defecation  and 
urination  in  most  cases  are  painful  or  difficult.  Reflex  and  sympathetic 
disturbances  of  extrapelvic  organs,  especially  the  organs  of  digestion, 
and  faulty  general  nutrition,  are  generally  present. 

Differential  Diagnosis. — The  differential  signs  are  between  metritis, 
small  fibroid  tumors,  and  early  pregnancy. 


Chronic  metritis 

1.  Menorrhagia  and  intramen- 
strual  uterine  hemorrhages,  not 
invariable. 

2.  Xo  signs  of  pregnancy. 


Small  fibroid  tumors 

1.  Menorrhagia    and    uterine 
hemorrhage  the  rule. 

2.  No  signs  of  pregnancy. 


Early  pregnancy 


3.  Uterus  hard  and  regular  in 
outline. 

4.  I"terus  commonly  in  path- 
ological anteversion  and  de- 
scent; may  be  in  retroversion. 


3.  Uterus  hard  and  irregular 
in  outline. 

4.  Uteru.s  liable  to  be  dis- 
placed in  any  direction  accord- 
ing to  the  mechanical  influence 
of  the  fibroids. 


1.   AmenorrhcBa. 


2.  Signs  of  early  pregnancy: 

a.  Morning  sickness. 

b.  Enlarged  breasts. 

c.  Blue    discoloration    of 

vaginal  mucosa. 

(I.  Softening  of  the  cer- 
vix uteri. 

e.  Hegar's  symptom  of 
narrow  supravaginal 
portion  of  the  cer\-ix. 

/.  Rhythmical  uterine- 
contraction  under 
the  palpating  hand. 

3.  Uterus  soft  and  regular  in 
outline;  may  momentarily  con- 
tract and  harden  on  handling. 

4.  Uterus  commonly  ante- 
verted. 


254      INFECTIONS,    INFLAMMATIONS,   AND  ALLIED  DISORDERS 

The  least  doubt  as  to  the  existence  of  pregnancy  should  lead  one 
to  await  developments.  Under  no  circumstances  should  the  sound 
be  passed  if  pregnancy  is  a  possibility. 

Treatment  of  Chronic  Metritis 

The  treatment  of  chronic  metritis  embraces  that  of  the  associated 
lesions.  The  reader  is  referred  therefore  to  the  treatment  of  endocer- 
vicitis,  endometritis,  perimetritis,  parametritis,  and  inflammation  of  the 
uterine  appendages. 

Numerous  operations  to  reduce  the  size  and  weight  of  the  uterus 
have  been  devised,  such  as  amputation  and  resection  of  the  cervix 
uteri;  but  as  already  set  forth,  enlargement  of  the  cervix  is  generally 
rather  apparent  than  real,  and  is  due  to  the  results  of  laceration.  See 
Emmet's  operation  and  Schroeder's  operation.  As  explained  in  the 
preceding  chapter,  when  the  wall  of  the  uterus  becomes  so  infected 
that  it  resembles  the  wall  of  an  abscess-cavity  the  organ  should  be 
removed.  Supravaginal  hysterectomy  sometimes  is  indicated  by  an 
enormously  enlarged  uterus,  especially  when  the  enlargement  is  asso- 
ciated with  disabling  displacement.  See  operation  for  supravaginal 
hy  steromy  omectomy . 


PLATE    VI 


FIGURE   1 


Follicular  Hydrosalpinx  (Caiarrnal  Salpingitis).     Cross-section 
Near  the  Middle  of  the  Tube. 

The  folds  of  the  swollen  mucosa  have  grown  together  so  that  the  deep  parts 
of  the  inflamed  mucosa  have  been  shed  off  partly  or  wholly  from  the  lumen  and 
have  formed  small  cysts,  a  frequent  result  of  catarrhal  salpingitis.  The  epithe- 
lium here  remains,  but  in  the  latter  stage  of  the  disease  it  may  be  destroyed. 
15  diameters. 

FIGURE  2 


Same  as  Figure  i.  Highly  magnified.  Here  also  are  shown  a  number  of 
variously  shaped  cavities.  The  high  mucous  folds  are  swollen  and  infiltrated 
with   the  round  cells  of  inflammation.      100  diameters. 


CHAPTER  XVIII 
SALPINGITIS 

Normal  Anatomy  of  Salpingitis 

The  Fallopian  tubes  are  developed  by  that  part  of  Mullcr's  ducts 
above  the  round  ligaments.     The  part  below  the  round  ligaments, 
together  with  the  Wolffian  ducts,  converges  to  form  the  uterus  aiul 
\agina.     The  mucous,  muscular,  and  peritoneal  layers  of  the  tubes, 
therefore,  are  continuations  of  the  corresponding  layers  of  the  uterus. 
By  analogy  of  uterine  nomenclature  these  three  layers  of  the  tube  are 
named  from  within  outward,  as  follows: 
The  endosalpinx — mucous  layer. 
The  myosalpinx — muscular  layer. 
The  perisalpinx — peritoneal  layer. 

The  Endosalpinx,  or  mucous  lining,  continuous  with  that  of  the  uterus, 
is  made  of  loose  connective  tissue  covered  with  a  single  layer  of  ciliated 
columnar  epithelium.  The  movement  of  the  cilia  always  is  directed 
toward  the  uterus,  and  probably  serves  to  propel  the  ovum  in  that  direc- 
tion. The  mucosa  at  the  uterine  end  is  relatively  smooth;  at  the  distal 
end  it  rises  in  numerous  high  folds.  This  is  shown  in  cross-section. 
(Plate  Vni.)  The  presence  of  glands  in  the  Fallopian  tube  has  been 
denied.  Bland-Sutton,  after  an  extensive  comparative  study  of  the 
tubes  of  the  lower  animals  and  of  woman,  declares  that  the  plications 
or  folds  of  the  tubal  mucous  membrane  "are  disposed  on  the  same 
principle  as  the  glands  in  the  uterus." 

The  probable  function  of  the  tubal  folds  is  to  provide  an  albuminous 
fluid  for  the  ovum  as  it  traverses  the  tube.  The  tube  participates 
only  in  slight  degree  if  at  all  in  menstruation.  As  shown  in  ectopic 
gestation  it  retains  some  power  to  develop  the  fertilized  ovum. 

The  Myosalpinx  is  made  of  two  muscular  layers,  internal  circular 
and  external  longitudinal.  These  layers  are  continuous  with  the  cor- 
responding layers  in  the  uterus.  It  is  not  known  whether  or  not  the 
tube  has  peristaltic  power. 

The  Perisalpinx,  or  peritoneal  investment  of  the  tube,  meets  the 
mucous  lining  at  the  abdominal  opening.  It  covers  about  four-fifths 
of  the  circumference  of  the  tube,  and,  converging  toward  the  broad 
ligament,  forms  a  narrow  mesosalpinx.  Between  the  layers  of  the 
mesosalpinx  is  an  abundance  of  loose  connective  tissue  through  which 
the  lymph-vessels  and  blood-vessels  and  nerves  directly  reach  the  tube. 

The  tubes  extend  from  the  horns  of  the  uterus  outward  on  either 
side  and  follow  a  bending  course  along  the  upper  border  of  the  broad 

(255) 


256      INFECTIONS,   INFLAMMATIONS,   AND   ALLIED   DISORDERS 

ligament  to  a  variable  length  of  from  three  to  four  inches.  They  are 
divided  into  four  parts:  the  interstitial  part,  th?  isthmus,  the  ampulla, 
and  the  fimbriated  extremity.  The  intersHtial  part  is  that  portion  which 
starts  from  the  endometrium  at  the  horn  of  the  uterus  and  runs  through 
the  uterine  wall.  From  this  point  the  tube  is  continued  as  the  isthmus 
or  isthmic  portion  and  runs  toward  the  lateral  wall  of  the  pelvis  about 
one  inch.  The  interstitial  and  isthmic  portions  have  very  small  caliber, 
especially  the  interstitial  which  at  the  ostium  uterinum  is  so  slight  as 
scarcely  to  admit  a  bristle.  This  constricted  portion,  unless  dilated  by 
disease,  would  prevent  an  intra-uterine  injection  or  secretion  from  enter- 
ing the  abdominal  cavity.  It  also  serves  to  protect  the  tube  against 
infection  from  the  uterus  and  the  uterus  against  infection  from  the  tube. 
The  ampulla  is  the  expanded  portion  of  the  tube,  and  easily  admits 
the  uterine  probe.  It  runs  from  the  isthmus  backward  and  downward 
around  the  outer  border  of  the  ovary,  and  terminates  in  an  expanded, 
trumpet-shaped  part  called  the  infundibulum.  The  fimbriated  extremity 
at  the  abdominal  opening  is  really  the  termination  of  the  ampulla. 
It  is  made  up  of  irregularly  shaped  processes,  all  freely  movable 
except  one,  w^hich  runs  along  the  tubo-ovarian  ligament  and  joins 
the  ovary.  These  fimbriae  are  branches  from  the  high  mucous  folds 
of  the  endosalpinx.  The  abdominal  ends  of  the  tube  usually  have  only 
one  opening.     Sometimes,  however,  the  openings  are  multiple. 


Etiology  of  Salpingitis 

Predisposing  Causes. — Among  the  local  predisposing  causes  are: 
parturition  and  abortion,  unclean  instrumentation  and  manipulation, 
infection  in  neighboring  organs  which  may  reach  the  tube  by  extension 
(tubal  disease  being  rarely  primary),  menstrual  congestion,  excessive 
coitus,  long  tortuous  tube  and  neoplasms. 

Among  the  general  predisposing  causes  are :  exanthemata,  visceral  dis- 
eases— those  of  the  heart,  lungs,  liver,  and  kidneys;  systemic  diseases, 
such  as  syphilis,  rheumatism,  and  gout. 

Exciting  Causes. — The  bacterial  exciting  causes  include  the  gono- 
coccus,  tubercle  bacillus,  streptococcus,  bacillus  coli  communis,  and 
staphylococcus.  Of  these  the  most  important  in  frequency  and  destruc- 
tive results  is  the  gonococcus,  which  is  present  in  more  than  two-thirds 
of  all  cases. 

Pathology  of  Salpingitis 

Salpingitis  which,  like  inflammation  elsew^iere,  may  be  acute  or 
chronic,  rarely  is  due  to  primary  infection  in  the  tube  but  usually  is 
secondary  to  infection  in  some  other  organ;  moreover,  infection  having 
reached  the  tube  is  very  apt  to  spread  to  adjacent  structures.  It  will 
become  necessary,  therefore,  in  the  course  of  this  discussion  to  consider 
not  only  incoming  but  also  outgoing  routes  of  infection. 


SALPINGITIS  257 

Incoming  Routes  of  Infection. — Inflaininatioii  of  the  Fallopian  tubes 
as  sot  forth  in  ('liai)tt'r  X.  occurs  frccjucntly  by  extension  of  infection 
from  the  uterine  nnicosa,  less  freciuently  from  infection  in  the  xaj^ina, 
bhidder,  or  rectum,  and  not  sehloni  from  extrapcKic  orj^^ans.  The 
l)rocess  may  spread;  by  contiiuiity  of  lym])h-\('ssels  and  blood-vessels 
in  the  uterine  and  tubal  mucosa,  in  the  uterine  nniscularis,  in  the  peri- 
metrium, and  in  tiie  ])ara-uterine  connecti\-e  tissue.  It  also  may  spread 
by  contiguity  from  extrapelvic  organs,  ])articularly  the  appendix  Ncrmi- 
formis,  or  it  may  extend  by  lymph-  or  blo()(l-^■essels  from  a  distant 
oruan,  for  example,  the  tuberculous  lung. 

Outgoing  Routes  of  Infection. — Infection  once  ha\ing  reached  the 
tubal  mucosa  may  extend  beyond  the  tube  in  three  ditt'erent  ways, 
as  follows:  1.  Through  the  abdominal  opening  to  the  peritoneum 
and  ovary.  2.  Through  the  walls  of  the  tube  by  way  of  the  lymph 
or  })lood  stream  or  by  rupture  to  the  peritoneum,  producing  peri- 
sali)ingitis,  i.  c,  local  peritonitis  which  may  extend  to  the  general 
peritoneum.  .').  Through  the  mesosalpinx  by  the  blood  or  lymph 
stream  or  by  rupture  into  the  loose  connective  tissue  between  the 
folds  of  the  broad  ligament,  producing  perilymphangitis  or  periphle- 
bitis, the  cellular  tissue  around  the  lymph  channels  or  veins  then  being 
inflamed,  the  condition  is  pelvic  cellulitis. 

Acute  Salpingitis. — The  tube  is  swollen  from  congestion  and  oedema. 
Abundant  pathological  secretion,  serous  or  purulent,  may  be  poured 
out  and  discharged  through  the  uterus  or  into  the  peritoneal  cavity, 
in  the  latter  event  giving  rise  to  great  danger  of  peritonitis.  INIore 
usually,  however,  the  two  ends  of  the  tube  are  occluded  either  by 
swelling  and  thickening,  or  by  adhesions  of  the  mucosa  so  that  the 
secretion  is  retained  within  the  tube,  which  in  consequence  becomes 
enlarged  by  distension  with  increasingly  thickened  walls  if  the  secre- 
tion is  purulent,  and  distended  thin  translucent  walls  if  the  secretion  is 
serous.  This  condition  is  known  under  the  generic  term,  sactosolpinx: 
such  retention  of  secretions  in  the  tube  is  nature's  method  of  limiting 
the  infection  and  arresting  the  progress  of  the  disease.  Some  bacteria, 
notably  gonococci,  have  great  power  to  set  up  defensive  adhesions; 
therefore  sactosalpinx  is  a  very  common  result  of  gonorrhoeal  infection. 
On  the  other  hand,  certain  bacteria,  notably  streptococci,  do  not  strongly 
excite  protective  adhesions,  hence,  the  greater  danger  of  peritonitis 
from  escaping  streptococcic  secretions  through  the  ampulla  into  the 
peritoneum.  Occlusion  from  swelling  does  not  continue  if  recovery 
by  resolution  takes  place.  That  from  adhesive  inflammation,  more  fre- 
quent in  purulent  than  in  catarrhal  salpingitis,  usually  is  permanent. 
All  three  layers  of  the  tube,  mucous,  muscular,  and  serous,  together 
with  the  adjacent  connective  tissue,  now  thickened,  turgid,  hard,  and 
sometimes  convoluted,  may  be  involved  in  what  is  known  as  diffuse  sal- 
inngiiis.  Adhesions  usually  form  between  the  perisalpinx  and  adjacent 
organs. 

The  minute  pathology  includes  sw^elling  from  oedema  and  consequent 
crowding  together  of  the  mucous  folds.  The  epithelial  cells  show 
17 


258     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 


Figure  122 


Hydrosalpinx.     Note  the  pear-shaped  tube. 


Figure   123 


Pyosalpinx.     Note  the  convoluted  tube. 


Figure   124 


Hsematosalpinx.     Note  the  pear-shaped  tube. 


SALl'LXaiTIS  259. 

ifranular  degeneration  and  cloiidy  swcllinu-  and  in  many  places  lifting  of 
the  basement  menil)rane.  Tlu'  fibers  of  the  connectiN-e  and  muscular 
tissue  are  separated  by  infiltration  of  small  round  cells  and  by  capillary 
engorgement. 

The  infhunmation  if  luuing  reached  the  tube  by  extension  from 
catarrhal  endometritis  will  be  catarrhal;  if  from  purulent  endometritis 
will  be  purulent;  if  having  spread  from  other  sources  will  correspond 
in  type  to  the  invading  bacteria;  for  example,  tubercular  appendicitis 
or  peritonitis  may  extend  to  the  tube. 

Chronic  Salpingitis. — Acute  and  chronic  salpingitis  frecpiently  shade 
otl"  into  one  another  so  that  the  difi'erence  between  them  may  be  one 
rather  of  degree  than  of  kind.  In  clironic  salpingitis  the  tube,  both 
the  uterine  and  distal  ends  of  it,  almost  always  become  (K-cluded  by 
adhesions,  thereby  giving  rise  to  sadosalpinx,  already  mentioned. 
The  bacteria  which  produce  the  disease,  although  present  in  acute 
salpingitis,  frequently  disappear  in  the  chronic  form,  so  that  very 
chronic  accumulations  of  pus  in  the  tube  usually  are  sterile.  It  is  said 
that  the  bacteria  die  from  the  accumulation  of  their  own  products. 
The  pus  being  sterile,  escape  of  it  into  the  peritoneal  cavity  whether 
from  rupture  during  an  operation  or  from  other  cause,  is  not  particularly 
dangerous. 

Sadosalpinx,  which,  as  above  indicated,  may  be  defined  as  distension 
of  the  tube  with  its  accumulated  secretions,  and  which,  clinically  speak- 
ing, is  much  more  common  in  chronic  than  in  acute  salpingitis,  has 
been  classified  under  three  divisions,  as  follows: 

Hydrosalpinx — sadosalpinx  serosa — is  a  serous  accumulation  in  the 
tube. 

Pyosalpinx — sadosalpinx  puridenta — is  a  purulent  accumulation  in 
the  tube. 

Hcematosalpinx — sadosalpinx  hcemorrhagica — is  an  accumulation  of 
blood  in  the  tube. 

The  following  tabular  statement  gives  the  comparative  pathology 
of  hydrosalpinx  and  pyosalpinx. 


Hydrosalpinx 

1.   Infection  by  extension  from  catarrhal  en- 
dometritis. 


Pyosalpinx 

1.   Infection  usually  by  extension  from  puru- 
lent endometritis. 


2.  Essentially  confined  to  mucosa — endosal-  2.  Apt  to  extend  and  become  diffuse,  involv- 
pingitis.  Walls  of  tube  in  acute  stage  slightly  ing  all  layers  of  tube.  Walls  of  tube  verj'  much 
thickened;  in  chronic  stage,  more  thickened.  thickened  and  infiltrated  with  round  cells. 
Complicating  peritonitis  not  common.  Peritonitis  common  as  a  complication, 

3.  Folds  of  mucosa  pressed  together  by  fluid  .3.  Folds  of  mucosa  may  be  adherent  or  oblit- 
contents;  epithelium  disappears  by  pressure  and  erated;  lumen  may  be  di^dded  partially  or 
folds  grow  together;  deeper  parts  of  inflamed  wholly  into  spaces  by  constrictions  or  adhe- 
mucosa  may  be  partlv  or  wholly  shut  off  from  sions;  these  spaces  may  be  distended  by  differ- 


lumen   and   by   small    cysts — salpingitis   pseudo- 
follicularis. 


ent  fluids;  hence  the  possibility  of  pyosalpinx, 
hydrosalpinx,  and  hsematosalpinx  in  one  tube 
with  lumen  composed  of  several  ca\-ities.  Verv 
much  thickened  walls  of  tube  may  contain 
small  abscesses  usually  formed  between  adherent 
folds  of  mucosa. 

4.   Mucous  folds  may  atrophy,  become  atten-  4.  Salpingitis  vegetans  never  occurs, 

uated,    and   floating   in   the   fluid   have   a   wavy 
appearance    described    by    Sawinoff    under    the 
name  salpingitis  vegetans.     Lumen  composed  of   I 
one  cavity.  I 


260     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 


Hydrosalpinx 

5.  Sactosalpinx   will    be   hydrosalpinx — i.    e., 
tube  distended  with  serum;  sometimes  hsemato- 


6.  Tubal  adhesions  absent  or  less  pronounced. 
Mobility  and  elasticity.  Fluctuation  through 
thin  walls. 


7.  Abdominal  end  of  tube  usually  closed  by 
adhesions  of  fimbria;  uterine  end  of  tube  less 
often  closed. 

8.  Sactosalpinx  may  be  due  to  occlusion  of 
tube  either  from  swelling  of  mucosa  or  adhesive 
inflammation:  if  the  former,  tube  may  period- 
ically discharge  contents  into  uterus  or  perito- 
neum, giving  rise  to  colicky  pains — hydrops  tubce 
profluens,  salpingitis  profluens. 

9.  Tube  thinned  and  translucent  in  propor- 
tion to  distension;  walls  atrophy:  fimbriae  grad- 
ually lost.  Tube  moderately  convoluted.  Size 
not  usually  larger  than  the  finger;  shape  regular 
spindle,  round,  elongated,  or  convoluted. 

10.  Not  apt  to  burst  into  adjacent  organs. 


11.  Odor  of  contents  not  offensive. 


Pyosalpinx 

o.  Sactosalpinx  will  be  pyosalpinx — i.  e., 
tube  distended  with  pus;  pus  may  contain  blood 
and  is  often  caseous. 

6.  Adhesions  usually  extensive  to  cul-de-sac 
of  Douglas,  walls  of  uterus,  broad  ligaments, 
or  posterior  segment  of  peKdc  floor;  tube  im- 
mobile and  inelastic.  Tube  and  ovary  may  be 
rolled  together,  universally  adherent.  Fluctua- 
tion masked  by  thickness  of  tubal  walls. 

7.  Both  ends  of  tube  closed  by  adhesive  in- 
flammation. 


8.  Tube  usually  occluded  by  permanent  in- 
flammatory adhesions;  hence,  salpingitis  pro- 
fluens less  frequent,  although  tube  may  rupture 
at  times  and  discharge  contents.  Purulent 
salpingitis  profluens  is  more  dangerous  than 
serous  salpingitis  profluens. 

9.  Tube  more  and  more  thickened  (irregular 
thickening)  in  proportion  to  distension,  much 
convoluted  and  nodular;  size  may  equal  that  of 
a  child's  head;  shape  most  irregular. 


10.  Frequently  bursts  into  intestine," rarely  into 
bladder. 

11.  Odor  very  offensive,  particularly  if  adherent 
to  bowel. 


Hydrosalpinx  in  one  tube  and  j^yosalpinx  in  the  other  are  not  un- 
common. Separate  compartments,  formed  by  occlusion  of  a  tube  at 
different  points,  may  result  in  distension  of  these  compartments  with 
different  fluids;  hence  there  may  be  in  the  same  tube  hydrosalpinx, 
pyosalpinx,  and  heematosalpinx. 

JIcBinatosalpinx  may  occur  as  the  result  of  hemorrhagic  salpingitis. 
An  inflamed  tube,  however,  must  contain  blood  in  considerable  quan- 
tities in  order  to  be  designated  clinically  by  the  term  hemorrhagic 
salpingitis  or  ha?matosalpinx.  Hemorrhage,  moreover,  may  occur 
in  a  tube  in  which  there  is  no  inflammation,  and  it  does  frequently  so 
occur  in  very  large  quantities,  even  to  the  extent  of  tubal  rupture, 
as  the  result  of  tubal  pregnancy,  for  a  description  of  which  the  reader 
is  referred  to  the  chapter  on  that  subject.  Usually  in  ha-matosalpinx 
due  to  inflammatory  causes  the  blood  is  not  clotted,  while  in  tubal 
pregnancy  it  is  clotted. 

Tuho-ovarian  Cyst  and  Tuho-ovarian  Abscess  may  form  as  follows: 
The  adhesion  of  a  sactosalpinx  to  an  ovary  may  be  followed  by  the 
bursting  of  a  small  ovarian  cyst  or  a  corpus  luteum  into  the  tube  and 
the  establishment  of  a  permanent  communication  between  the  two. 
During  the  growth  of  the  tubal  sac,  which  is  now  part  of  a  tubo-ovarian 
cyst,  the  ovarian  cyst  is  subject  to  the  same  pressure  as  the  walls  of 
the  tube;  hence  the  ovarian  structure  becomes  flattened  so  as  to  form 
a  thin  wall  for  the  ovarian  portion  of  the  composite  cyst,  and  thus  the 
characteristic  structure  of  the  ovary  is  lost.  This  is  not  to  be  confounded 
with  ovarian  hydrocele,  which  is  described  elsewhere.  Tubo-ovarian 
cyst,  see  Chapter  on  Ovarian  Tumors,  may  occur  in  connection  with 
hydrosalpinx  or  pyosalpinx.  If  the  sactosalpinx  communicates  with  an 
ovarian  abscess,  the  condition  is  called  tubo-ovarian  abscess. 


PLATE    IX 


■I^^'!^^''^^--^'^^^^!!^ 


aroo<f 


-'f- 
<>>lii» 


--^S.*" 


P«RKER 


A 


:>S<r^': 


.*^..' 

♦o^"' 


"'*  ,;^*;.    "^ 


A.  Diffuse  Hemorrhagic  Salpingitis.  Section  between  the  middle  and  outer 
third  of  the  tube.  The  high  mucous  folds  and  the  walls  of  the  tube  are  much 
swollen  and  congested. 

B.  Section  from  the  wall  of  the  tube  A. 

C.  Section  from  the  mucous  folds  of  the  tube  A.  Sections  A  and  B  both 
show  congested  thickening,  hemorrhagic  areas  and  infiltration  with  many  small 
round  cells  of  inflammation. 

A  magnified  lo  diameters.  B  magnified  loo  diameters.  C  magnified  jo 
diameters. 


SALPIXaiTIS  201 

The  associdlctl  jxifhologi/  of  mlphujilis  w  liidi  for  the  most  part  is  the 
result  of  e.\teiisit)ii  of  the  iiiHamniatory  process  from  the  tul)e  to  neif^h- 
horing  structures  will  be  takeu  up  in  the  followiii^^  chapter  on  Pelvic 
Cellulitis,  l'el\  ie  Peritonitis,  and  Ovaritis. 

Symptoms  of  Salpingitis 

There  are  no  pathognomonic  symptoms  of  salpin<i;itis.  The  disease 
usually  is  so  closely  related  to  i)elvic  peritonitis  and  oN-aritis  that  the 
symptoms  and  diagnosis  of  these  conditions  are  included  largely  in 
those  of  salpingitis.  The  combined  inflammations,  usually  designated 
as  adnc.val  inflammation  or  inflammation  of  the  uterine  appendacjea, 
vary  in  respect  to  symptoms  with  the  virulence,  acuteness,  complica- 
tions, and  mechanical  conditions  of  the  disorder.  Usually  the  tubes 
except  the  peritoneal  layer  are  less  sensitive  to  pain  than  the  ovaries; 
the  pain  of  salpingitis  is  increased  therefore  when  the  disease  includes 
peritonitis  and  ovaritis.  The  milder  catarrhal  inflammations,  even 
though  acute,  may  cause  symptoms  so  slight  as  scarcely  to  fix  the 
patient's  attention  upon  the  diseased  part  and  may  even  run  their 
course  and  disappear,  leaving  no  trace  except  perhaps  greater  liability 
to  future  infection.  Such  unrecognized  mild  congestive  and  catarrhal 
attacks  probably  are  more  frequent  than  is  generally  supposed.  The 
local  pain  or  discomfort  in  the  affected  part  does  not  always  correspond 
to  the  seriousness  of  the  infection.  There  may  be  only  dull  aching  or 
a  sensation  of  burning  not  sufficient  to  impress  the  patient  unless 
mechanically  aggravated  as  by  local  pressure,  as  exertion  or  defecation, 
and  yet  the  tube  may  be  distended  \vith  serum  as  pus,  ready  to  burst 
into  the  peritoneal  cavity. 

Acute  Salpingitis. — Usually  the  characteristic  signs  of  inflammation 
are  present,  that  is,  chill,  fever,  rapid  pulse,  pain  localized  on  the 
affected  side  or  sides,  and  increased  uterine  secretion  and  variable 
hemorrhage.  The  pain  is  perhaps  more  apt  to  be  marked  in  gonorrhoeal 
than  in  most  of  the  other  tubal  infections,  especially,  if  as  frequently 
occurs,  there  is  additional  pain  from  associated  vulvovaginitis,  metritis, 
urethritis,  and  cystitis. 

Chronic  Salpingitis  in  varying  degrees  wdll  include  dull  and  sometimes 
burning  pain,  and  local  tenderness,  w^hich  may  be  constant,  remittent, 
or  intermittent.  Occasional  exacerbations  of  pain  due  to  local  peritonitis 
from  leakage  of  the  tube  or  from  other  sources  are  rather  characteristic 
of  adnexal  inflammation.  Colicky  pains  in  the  region  of  the  tubes 
are  strongly  diagnostic.  This  symptom  not  infrequently  occurs  w  ith 
variable  intervals  of  comparative  comfort.  It  is  claimed  by  some  to 
indicate  gonorrhoeal  infection.  It  is  frequent  in  prostitutes  and  there- 
fore has  been  called  colica  scortorum.  This  symptom  has  been  variously 
and  not  very  clearly  attributed  to  salpingitis  perfluens,  spasmodic 
contractions  of  the  muscular  walls  of  the  uterus  or  tube,  peritoneal 
irritation,  leakage  of  tubal  secretion  into  the  peritoneum,  and  periodical 
rupture  of  the  walls  of  the  tube. 


262      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

During  the  monthly  period  the  pathological  congestion  is  supplemented 
by  that  of  menstruation;  hence  the  pains  are  increased  and  dysmenor- 
rhoea  is  not  infrequent.  Increased  menstrual  flow,  even  to  the  extent 
of  menorrhagia,  is  common.  Amenorrhoea  or  scanty  menstruation 
seldom  is  observed,  and  when  present  points  to  possible  tuberculous 
infection. 

Greatly  dilated  and  swollen  tubes,  especially  when  associated  with 
local  peritonitis,  always  produce  mechanical  disturbances.  The  more 
gradual  the  swelling  and  the  more  opportunity  the  parts  have  therefore 
to  adapt  themselves  to  new  conditions,  the  less  the  pain.  The  mechanical 
symptoms  are  variable  and  numerous.  They  include  painful  urination 
and  difficulty  and  pain  on  walking  and  standing. 

The  comparative  symptoms  of  catarrhal  and  purulent  salpingitis  are 
outlined  in  this  tabular  statement: 

Catarrhal  salpingitis  '        I  Purulent  salpingitis 

1.  Fever  present  in  acute  stage  and  usually  1.  Fever  high  in  acute  stage.  Usually  slight 
absent  in  chronic  stage.                                                   I   evening   temperature   in   chronic   stage.      If   pus 

becomes  sterile,  temperature  may  be  normal. 

2.  Pain  in  region  of  tube  variable  in  acute  stage;  !  2.  Pain  and  systenaic  disturbance  (anxious 
usuallv  absent  or  almost  absent  in  chronic  stage.    1   facies,   nausea,   depression)   more  pronounced  in 

•    I   acute    stage.      Pain    and    general    malnutrition 
]   usually    present    in    chronic    stage.      Symptpms 
partly   due   to   extension   of   infection  to   neigh- 
boring  organs,    producing    ovaritis,    pelvic   peri- 
tonitis, and  cellulitis. 


3.   Salpingitis  profluejis  not  uncommon. 


.3.   Salpingitis  profluens  uncommon. 


Diagnosis  of  Salpingitis 

The  symptoms  set  forth  in  the  foregoing  paragraphs  point  to  the 
probability  of  inflammation  in  the  pelvis.  Indeed,  it  is  usually  easy 
to  recognize  the  presence  of  acute  pelvic  inflammation,  especially  when 
inflamed  organs  are  crowded  with  products  of  inflammation.  The 
subjective  symptoms  in  the  milder  cases  may  be  overlooked;  and,  as 
already  stated,  the  existence  even  of  pyosalpinx  sometimes  is  unrecog- 
nized until  rupture  of  the  tube  and  escape  of  pus  have  set  up  dangerous 
peritonitis.  Therefore  the  presence  of  endometritis  should  keep  one 
on  guard  even  against  a  possible  secondary  salpingitis. 

There  is  usually  a  recent  or  remote  antecedent  background  of  acute 
or  chronic  infection  in  some  neighboring  organ;  the  diagnosis  there- 
fore should  include  both  the  inflamed  appendages  and  the  antecedent 
causative  inflammation,  usually  endometritis,  but  sometimes  vaginitis, 
vulvitis,  cystitis,  proctitis,  or  appendicitis. 

Physical  examination,  which  should  be  conducted  with  great  care  in 
order  to  avoid  rupture  of  a  pus-tube  or  other  abscess-wall,  is  made  by 
external  palpation  over  the  hypogastrium  and  by  conjoined  manipula- 
tion. The  former  is  usually  inadequate.  The  latter,  which  includes 
external  palpation,  is  made  with  the  left  index-finger  in  the  vagina 
and  the  right  hand  over  the  hypogastrium;  or,  as  set  forth  in  Chapter 
III.,  with  the  left  index-finger  in  the  rectum,  the  thumb  in  the  vagina, 
and  the  right  hand  over  the  hypogastrium.     Light,  conjoined  palpa- 


SALPINGITIS  2G3 

tioii  will  show  an  irregular  t-lcjugated  swclliiifi;  on  one  or  both  sides  of 
the  uterus,  fre(iuently  extendinjj  into  the  i)oueh  of  Doufjlas,  or  some- 
times even  in  front  of  the  uterus.  It  often  is  impossible  to  make  out 
the  component  parts  of  such  a  mass.  They  will  include  usually  the 
inflamed  tuhe  or  tubes,  which  may  be  confused  in  varying  degree 
with  diseased  ovaries,  peritoneum,  intestine,  omentum,  bladder,  and 
uterus,  not  to  mention  other  morbid  conditions  such  as  neoplasms 
which  may  be  unrecognized.  These  structures  may  be  matted  together 
in  an  irregular,  indefinite  tumor.  The  one  nearly  constant  factor  is 
salpingitis.  Sactusalpiti:c,  if  possible  to  outline,  will  appear  as  an 
irregular-shaped,  sausage-shaped,  pear-shaped  or  retort-shaped  mass 
connected  with  the  uterus,  the  constricted  portion  of  which  will  be  at 
the  isthmus. 

The  Distinction  of  One  Form  of  Bacterial  Infection  from  Another  must 
depend  upon  the  examination  of  the  secretions  for  bacteria.  Such 
an  examination  is  always  desirable,  but  sometimes  impracticable. 
The  \'iilvovaginal  and  uterine  secretions  in  the  acute  stage  not  infre- 
quently contain  the  causative  germs.  Pus  long  confined  in  the  tube  is 
apt  as  before  mentioned  to  become  sterile.  This  explains  the  freedom 
from  infection  so  often  observed  after  a  pus-tube  has  ruptured  within 
the  peritoneal  cavity.  The  inflammation  may  continue  long  after 
the  original  bacteria  have  disappeared,  or  at  least  after  their  presence 
no  longer  can  be  demonstrated. 

Gonorrhceal  salpingitis  may  be  recognized  tentatively  by  the  history 
of  suspicious  exposure,  the  presence  of  gonorrhoeal  infection  in  the  Milva, 
vagina,  or  uterus,  and  by  usual,  though  not  invariable,  bilateral  infection. 

Tubercular  Salpingitis  generally  is  secondary  to  tuberculosis  in  other 
organs,  and  is  of  frequent  occurrence.  ^Miitridge  Williams  found  it  in 
7.7  per  cent,  of  91  cases.  It  very  rarely  occurs  from  direct  infection  by 
coitus  or  other  media.  It  has  been  observed  as  early  as  the  fifth  year 
of  life,  and  is  the  most  frequent  form  of  salpingitis  found  in  virgins. 
It  often  attacks  both  tubes  and  involves  the  neighboring  peritoneum; 
in  fact  it  must  be  firmly  borne  in  mind  that  tubercular  salpingitis  ven,' 
generally  is  only  a  part  of  a  much  more  generalized  infection,  especially 
of  the  general  peritoneum  and  abdominal  viscera.  Tubercular  pelvic 
disease  is  characterized  by  mild  pyrexia,  weakness,  often  splenic  en- 
largement, and  thickening  of  the  subperitoneal  tissues.  The  tendency 
of  the  disease  is  toward  atresia  of  the  tube  and  the  formation  of 
pyosalpinx  which  generally  precludes  demonstration  of  tubercle 
bacilli  in  the  vaginal  discharges. 

Tubercular  salpingitis  may  be  acute  or  chronic.  The  abdominal 
end  of  the  tube  is  in  general  open  in  the  acute  and  closed  in  the  chronic 
cases;  the  contents  of  the  closed  tube  are  serous  or  purulent.  The 
mucosa  in  acute  cases  may  contain  many  small  tubercular  nodules. 
In  these  nodules  are  found  giant  cells  and  many  tubercle  bacilli. 
Chronic  tubercular  sactosalpinx  often  is  a  large  sac  containing  thin, 
thick,  or  caseous  pus.  The  mucosa  is  destroyed,  and  the  sac  is  lined 
with  granular  tissue  which  contains  numerous  giant  and  epithelioid 


264      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

cells.  The  tubercle  bacillus  in  this  tissue  is  often  impossible  to  find. 
The  perisalpinx  presents  the  same  microscopical  appearances  as  the 
mucosa — that  is,  there  are  numerous  giant  cells  and  few  if  any  tubercle 
bacilli.  Chronic  fibroid  tuberculosis  of  the  tubes  is  a  peculiar  form 
described  by  Williams.  In  this  variety  the  formation  of  connective 
tissue  is  the  final  stage  of  the  tubercular  infection.  The  contracting 
fibrous  tissue  around  the  tubercular  nodules  crushes  out  the  miliary 
ti^bercles  and  may  prevent  spread  of  the  disease. 

Figure  125 


Tubercular  Fallopian  tube.     Observe  the  pearl-like  tubercles  thickly  studded  over  the  surface. 

Diagnosis  of  Tuberculous  from  other  Forms  of  Salpingitis. — On  account 
of  the  similarity  of  symptoms  and  physical  signs  the  diagnosis  may 
be  very  difficult.  In  comparison  with  the  other  forms,  chronic  tuber- 
cular infection  is  more  apt  to  show  an  evening  rise  in  temperature  of 
about  one  degree,  and  a  marked  increase  in  the  frequency  of  the  pulse. 
Pain  and  menstrual  disturbances  are  not  particularly  diagnostic. 
Ascites  occurs  in  many  cases  and  is  diagnostic.  The  physical  signs 
are  substantially  the  same  as  in  other  forms  of  salpingitis.  Among 
the  diagnostic  points  are: 

Tuberculosis  in  other  organs  with  symptoms  intensified. 

Family  history  of  tuberculosis. 

Salpingitis  in  virgins;  tubercular  in  90  per  cent,  of  all  cases. 

Chronicity  and  absence  of  very  acute  exacerbations. 

Scanty  menstruation  or  amenorrhoea;  not  uncommon. 

Ascites;  not  uncommon. 

Palpation  of  tubercular  nodules  sometimes  possible. 
The  usual  microscopic  blood  and  vaccine  tests  of  tuberculosis  in 
general  are  equally  applicable  in  tubercular  salpingitis. 

The  differentiation  of  the  various  adnexal  inflammations  from  one 
another,  especially  in  the  acute  stage,   is  often  difficult.     Ovaritis, 


SALI'INGiriS 


265 


usually  a  consequence,  sometimes  a  cause  of  salpinj^itis,  is  not  easily 
(listin,<:;uishe(l  from  it  when  the  two  ()r<i;ans  are  fused  toffcther  by 
adhesions,  and  when  the  tnl)e  is  distended  with  Ihiid,  the  difheulty  is 
increased. 

Differential  Diagnosis. — Suetosalpinx  closely  resemhles  many  other 
conditions,  inllannnatory  and  non-inflammatory,  the  dill'erentiation  of 
which  is  set  forth  in  the  followinii;  j)arallcl  columns: 


Sactosalpinx 

Septic  ponclition  and  pain. 

Commonly  l)ilaterui. 

Tube  oblon';  and  tortuous. 

Commonly  aJhcrent. 

Ovary  often  palpated  and  distinguished. 

Usually  not  larger  than  fist. 

Leucocytosis  usual. 

Saclosalpinx 

Common. 
Usually  bilateral. 
Sensitive  to  pressure. 
Usually  fixed. 
Elastic  or  fluctuating. 
Result  of  infection. 

Sactosalpinx 

Usually  sharply  circumscribed  and  of  rounded 
contour. 

Commonly  bilateral. 

Elastic  and  fluctuating.     Not  a  reliable  sign. 

Position  relative  to  uterus:  mass  usually  higher 
in  pelvis  near  fundus  uteri;  not  connected  with 
cer\'ix.     Vaginal  vault  not  depressed. 

Sactosalpinx 

Mass  usually  elastic;  may  fluctuate. 
Adhesions  common. 
Sensitive  to  pressure. 
Uterine  end  of  tube  enlarged. 

History  of  infection. 


Sactosalpinx  (right  side) 
Tumor  felt  by  vaginal  touch. 


.\fter  acute  stage,  size  of  tumor  may  not  mate- 
rially diminish. 
Recurrence  less  dangerous  and  less  frequent. 
Gastro-intestinal  disturbances  somewhat  marked. 


Cystic  ovarian  tumor 

Absent. 

Commonly  unilateral. 

Spheroidal  or  spherical. 

Less  commonly  adherent. 

Tumor  is  diseased  ovary. 

May  grow  to  enormous  size. 

No  leucocytosis  unless  infected. 

Solid  tumor  of  tube 

Rare. 

Usually  unilateral. 

Not  sensitive. 

Usually  free  and  mobile. 

Firm  consistence. 

Cause  unknown. 

Pelvic  cellulitis 

Not  sharply  circumscribed;  may  be  flattened. 

Commonly  unilateral. 

Less  elastic  and  fluctuating.     Not  reliable. 

Position    relative    to    uterus,    usually    lower    in 

pelvis,    often    closely    connected   with    uterus. 

Vaginal  vault  commonlj'  depressed. 

Tubal  pregnancy 

Consistence  often  quite  firm. 

Less  common. 

Not  sensitive. 

Commonly     normal     except     interstitial     tubal 

pregnancy. 
History  of  pregnancy. 

a.  Amenorrhcea. 

6.   Increase  in  size  of  uterus. 

c.  Enlargement  of  breasts. 

d.  Morning  sickness. 

e.  Rupture  of  tube  with  great  pain,   collapse 

(pelvic  haematocele),  uterine  hemorrhage, 
and  discharge  of  decidual  membrane. 

Appendicitis 

Tumor  not  usually  within  reach  of  vaginal  touch, 
but  is  felt  or  is  tender  to  pressure  on  external 
palpation  in  region  of  McBurney's  point. 

After  acute  stage,  tumor  apt  to  disappear. 

Recurrence  more  dangerous  and  more  frequent. 
Decidedly  marked. 


Among  the  other  conditions  which  may  in  some  respects  resemble 
sactosalpinx  are  these: 


Displaced  uterus. 

Tumors  of  the  sacrum  and  ilium. 

Fecal  accumulations. 


Displaced  abdominal  organs. 
Adherent  intestine. 
Intestinal  tumors. 


Study  of  the  diagnosis  of  lateral  and  backward  versions  and  flexions 
of  the  uterus,  and  of  Uterine  Myomata,  will  enable  the  .student  to  dis- 
tinguish these  conditions  from  sactosalpinx.    See  index. 


266      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

Tumors  of  the  sacrum  and  ilium  are  distinguished  by  their  location, 
hardness,  immobility,  and  intimate  relations  with  the  bony  pelvis. 

Fecal  accumulations  may  be  recognized  by  palpation,  and  may  be 
removed  by  cathartics. 

Displaced  kidney,  spleen,  and  other  abdominal  viscera,  intestinal  adhe- 
sions and  intestinal  tumors,  usually  may  be  recognized  by  their  remote- 
ness from  the  uterus,  or  by  the  fact  that  on  manipulation  they  may 
be  separated  from  that  organ.  The  author  has  had  a  case  of  tumor 
of  the  sigmoid  flexure  adherent  to  the  cul-de-sac  of  Douglas,  and  on 
conjoined  examination  having  all  the  appearance  of  a  large  sactosal- 
pinx.  Diagnosis  was  made  only  after  enucleation  of  the  mass  from  its 
surroundings. 

Anaesthesia  is  often  necessary  in  order  to  relax  the  abdominal  muscles 
and  thereby  permit  more  efficient  palpation  with  the  minimum  force, 
and  consequently  with  the  minimum  risk.  Unnecessary  laparotomies 
often  would  be  avoided  by  such  careful  diagnosis.  The  bladder  and 
bowel  should  be  evacuated  as  a  prerequisite  to  examination. 

Exploratory  Incision. — In  serious  pelvic  disease  the  diagnosis,  if 
not  possible  or  satisfactory  by  the  above  means,  may  be  made  by 
exploratory  vaginal  or  abdominal  section.  The  incision  may  become 
the  first  step  of  a  radical  operation  or,  if  the  operation  prove  un- 
necessary, may  be  closed  safely.  It  is  a  good  rule  always  to  begin  a 
peritoneal  operation  as  a  diagnostic  exploratory  incision.  As  Mr.  Tait 
wisely  remarked,  "It  is  better  to  turn  an  exploratory  incision  into  an 
operation  than  it  is  to  turn  an  operation  into  an  exploratory  incision.'^ 
The  late  Charles  T.  Parkes,  w^hen  questioned  by  a  bystander  at  the 
beginning  of  an  abdominal  section,  replied,  "I  don't  know  what  it  is, 
and  I  am  tired  of  guessing." 

Prognosis  of  Salpingitis 

In  acute  adnexal  inflammation  the  prognosis  varies  with  the  nature 
of  the  infection  and  with  the  extent  of  the  disease.  If  the  tube  ruptures 
and  discharges  pus  into  the  peritoneum,  a  fatal  peritonitis  may  follow. 
If  infection  is  confined  to  the  tube,  the  prognosis  is  usually  favorable, 
but  the  removal  of  the  appendages  may  be  necessary  for  permanent 
recovery. 

Simple  catarrhal  salpingitis  may  run  its  course,  perchance  unrecog- 
nized, to  recovery,  leaving  no  trace  except  an  increased  liability  to 
further  inflammation.  The  rule  that  sactosalpinx,  especially  the  puru- 
lent variety,  does  not  recover  without  operative  interference,  is  not 
without  exception,  for  pus  cavities  may  rupture  spontaneously  and 
discharge  their  contents  through  the  bowel,  uterus,  bladder,  vagina, 
or  cutaneous  surface,  and  recovery  may  follow;  but  such  a  possibility 
does  not  offer  substantial  hope  of  relief.  In  fact,  even  when  such 
rupture  and  discharge  are  followed  by  relief,  the  result  is  usually  only 
temporary,  and  the  patient  may  succumb  to  continued  infection. 

Salpingitis  will  cause  loss  of  function,  and,  if  the  disease  is  bilateral, 


SALPixaiTis  267 

sterility,  In  pcrinaiuMit  closuri'  of  the  tiilx's.  I'linileiit  sactosalpiiix 
is  a  constant  dan.mT  even  to  life.  'IMie  streptococcus  is  apt  to  destroy 
life,  while  the  j^^onococciis  in  a  physiolo^^ic  al  sense  destroys  the  repro- 
ductive ortjans  and  makes  a  chronic  invalid. 

The  danger  of  operation  varies  with  the  extent  of  the  disease,  the 
kind  of  operation,  the  nature  of  the  causal  bacteria,  and  above  all,  with 
the  operator.  The  mortality  shown  by  the  statistics  of  some  operators 
is  enormous;  other  reports  give  almost  100  per  cent,  of  recoveries. 
The  more  chronic  the  disease,  the  less  danger  of  operation.  The  prog- 
nosis of  the  operation  is  affected  favorably  by  the  removal  of  the  appen- 
dages without  rupture  and  escape  of  pus  into  the  pelvic  cavity.  The 
average  mortal  if  i/,  with  modern  asepsis  and  technique,  should  not  exceed 
2  per  cent.,  except  for  acute  cases;  usually  these  are  treated  more  safely 
by  vaginal  incision  and  drainage  than  by  abdominal  section. 

Treatment  of  Salpingitis 

The  treatment  will  be  found  in  Chapter  XX. 


CHAPTER   XIX 

ASSOCIATED   LESIONS  OF   SALPINGITIS— PELVIC  CELLU- 
LITIS,  PELVIC   PERITONITIS,   AND   OVARITIS 

Although  the  relation  of  cause  or  effect  is  not  constant  between 
salpingitis  and  adjacent  inflammations  of  the  cellular  tissue,  peritoneum, 
and  ovaries,  yet  the  interlocking  of  these  infections  with  salpingitis  is 
so  nearly  constant  as  to  justify  the  consideration  of  them  as  associated 
lesions. 

PELVIC   CELLULITIS 

Anatomy 

An  abundance  of  loose  cellular  tissue  binds  all  the  pelvic  viscera 
together.  It  is  continuous  with  the  cellular  tissue  of  the  uterus  and 
its  appendages,  and  is  found  in  large  quantities,  especially  in  the  broad 
ligaments.  It  is  the  medium  through  which  the  lymph-  and  blood- 
vessels and  nerves  connect  the  uterus  with  its  appendages,  and  bring 
them  all  into  close  anatomical,  physiological,  and  pathological  rela- 
tions. The  cellular  tissue,  and  particularly  that  of  the  broad  liga- 
ments, becomes  therefore  a  most  significant  factor  in  pelvic  infection. 
Cellular  tissue  of  the  pelvis  binds  the  various  pelvic  organs  together 
and  fills  nearly  all  the  space  in  the  pelvis  not  occupied  by  them;  it 
exists  in  great  quantities  around  the  uterus,  vagina,  rectum,  bladder, 
and  the  psoas  and  iliacus  muscles,  and  furnishes,  therefore,  an  abun- 
dance of  material  for  the  development  of  cellulitis. 

Exception  sometimes  has  been  taken  to  the  name  cellulitis,  since 
all  tissues  are  cellular,  and  since,  therefore,  in  the  wide  sense,  all  inflam- 
mation is  cellulitis.  The  word  is  used  here  in  accordance  with  estab- 
lished usage,  and  is  limited  to  inflammation  of  the  cellular  tissue  around 
the  uterus  and  vagina,  more  especially  that  between  the  folds  of  the 
broad  ligaments.  The  term  parametritis  is  too  restricted,  since  the 
disease  may  occur  in  the  lower  regions  of  the  peh'is  around  the  vagina 
and  bowel.  Cellulitis  usually  is  associated  with  some  degree  of  peri- 
tonitis and  therefore  is  related  to  it  much  as  pneumonia  is  related  to 
pleuritis. 

Etiology  of  Pelvic  Cellulitis 

Cellulitis,  or,  as  it  sometimes  is  called,  j)^^^"?^  parametritis,  is  not 
unusually  of  puerperal  origin;  the  causes  therefore  are  largely  iden- 
tical with  those  of  puerperal  infection.    The  etiology  in  general  is  con- 

(268) 


PKIA'IC   CELLriJTIS  269 

sidered  in  Chapter  X.  Tlic  most  freciuciit  hactcria  in  cellulitis  are 
the  common  pus  cocci.  The  inuucdiate  source  of  infection  is  usually 
salpingitis,  hut  it  may  arise  in  the  j)erineum,  \a^ina,  bladder,  or  rectum. 
The  infected  rectum,  urethra,  and  bladder  are  fretiuent  sources  of  celhi- 
litis  in  men.  Unclean  therapeutic  appliances,  sej:)tic  manii)ulations 
fjjenerally.  and  traumatisms,  especially  those  of  parturition,  open  the 
way  for  the  entrance  of  the  bacteria. 

Pathology  of  Pelvic  Cellulitis 

The  region  most  frequently  aflfected  is  the  cellular  tissue  between 
the  folds  of  the  broad  ligaments,  to  which  infection  may  be  introduced 
through  the  tube-wall  or  uterine-wall  by  the  blood  or  lymph  stream, 
or  it  may  be  carried  directly  by  rupture  of  the  tube  through  the 
mesosalpinx.  The  progress  of  the  infection  may  now  be  checked  by 
thrombic  plugging  of  the  vessels  and  destruction  of  their  lumina;  if 
resolution  does  not  follow,  the  thromboses  break  down  and  the  corre- 
sponding spaces  are  filled  with  pus.  The  infection  then  will  spread  to 
the  surrounding  cellular  tissue.  The  disease  in  its  full  development 
therefore  is  cellulitis.  Hence  to  define  cellulitis  as  yerilymphaiicjUis  or 
periphlebitis  would  be  strictly  accurate. 

Cellulitis,  like  other  inflammations,  is  divided  into  three  stages: 
1,  congestion;  2,  effusion;  and  3,  suppuration. 

The  disease  may  terminate  in  the  first  or  second  stage  by  resolution 
and  complete  recovery  or  may  continue  as  chronic  cellulitis,  or  it  may 
go  on  to  suppuration,  in  which  event  numerous  small  abscesses  may 
coalesce.  The  pus  may  escape  along  the  meshes  of  the  loose  connec- 
tive tissue,  avoiding  firmer  and  stronger  parts,  and,  unless  opened  by 
incision,  may  burst  into  the  vagina,  bladder,  urethra,  or  intestine,  or 
above  Poupart's  ligament,  rarely  below  it,  or  into  the  labia  majora, 
peritoneal  cavity,  or  lumbar  region,  or  through  the  obturator,  sacro- 
sciatic,  or  saphenous  openings.  Abscesses  of  cellulitis  origin  most 
frequently  burst  into  the  vagina;  those  of  tubal  origin,  especially  if 
surrounded  by  peritoneum,  are  more  apt  to  break  into  the  bowel  or 
bladder.  The  bursting  of  an  abscess  through  the  cutaneous  surface 
or  into  an  organ  which  affords  ready  drainage,  may,  if  not  followed  by 
fresh  infection,  result  in  spontaneous  cure. 

In  very  severe  cases,  with  extensive  invasion  of  the  lymphatics,  the 
whole  cellular  tissue  of  the  pelvis  may  be  involved  in  paracystitis, 
paracolpitis,  paraproctitis,  parametritis,  salpingitis,  and  ovaritis. 
Such  infection  usually  results  in  abscesses,  and  great  systemic  disturb- 
ance is  apt  to  be  of  streptococcus  origin,  and  is  know^n  as  the  erysipelas 
maJignum  internum  of  Virchow.  The  clinical  picture  in  these  cases  is 
that  of  an  acute  general  septicaemia.  The  infection  may  result  in  general 
peritonitis,  and  accumulation  of  pus  may  form  throughout  the  abdomi- 
nal cavity.  The  conflition  is  rare  and  the  mortality  high.  Extensive 
permanent  chronic  trophic  changes  may  follow. 

In  contrast  with  the  virulent  cellulitis  just  described  is  the  so-called 


270      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

cellulitis  of  Stapfer.  It  consists  of  oedematous  indurations  in  the  ab- 
dominal walls  and  in  the  floor  of  the  pelvis,  and  is  characterized  by 
pelvic  discomfort  and  inconstant,  transitory,  or  severe  pain.  The 
inflammation  is  of  very  mild  type,  with  slight  systemic  disturbance. 
The  transient  nature  of  the  disease  suggests  the  analogy  of  urticaria 
and  a  probable  angioneurotic  element  in  its  causation.  Stapfer  declares 
that  the  condition  is  common,  and  often  mistaken  for  more  serious 
affections. 

Associated  Pathology. — Cellulitis  gives  rise  to  numerous  displace- 
ments and  distortions  of  the  pelvic  organs,  by  adhesions  and  cicatrices, 
chief  among  which  are: 

a.  Uterus  drawn  forward,  backward,  or  to  either  side. 

b.  Ovaries  and  tubes  displaced  and  fixed. 

c.  Bladder  displaced  or  distorted. 

d.  Rectum  constricted  (rarely). 

Adhesions  and  cicatrices  around  the  rectum  and  bladder  may  result 
in  contraction  of  these  viscera  and  shortening  of  the  vagina.  The 
atrophic  contracted  cicatrix-like  cellular  tissue  may  cause  excessive 
versions  and  flexions  of  the  uterus.  Pressure  from  the  contracting 
scar  formation  causes  perineuritis,  neuritis,  and  obstruction  of  the 
vessels  and  uterus,  thus  giving  rise  to  pain,  malnutrition,  reflex  nervous 
disturbance,  and  chronic  invalidism. 

Symptoms  and  Diagnosis  of  Pelvic  Cellulitis 

The  symptoms  are  nearly  identical  with  those  of  inflammation  of  the 
uterine  appendages.  In  acute  cellulitis  there  will  be  severe  radiating 
pain,  in  many  cases  pain  shooting  down  the  thighs,  high  fever,  chills, 
general  pelvic  sensitiveness,  inability  to  walk  or  stand,  and  painful 
urination  and  defecation.  Acute  symptoms  may  decrease,  and  when  sup- 
puration occurs  reappears,  modified  by  the  signs  of  pus-formation — that 
is,  chflls  and  hectic  fever. 

The  symptoms  outlined  in  the  foregoing  paragraph  always  would 
suggest  a  tumor  in  the  pelvis  composed  of  products  of  inflammation, 
w^hich,  if  present,  may  be  felt  as  a  hard  or  boggy  mass,  extremely 
tender,  usually  in  the  lower  portion  of  one  of  the  broad  ligaments, 
crowding  the  uterus  to  the  opposite  side  of  the  pelvis  and  bulging  into 
the  vagina.  Xot  infrequently  the  uterosacral  folds,  so-called  ligaments, 
are  involved.  ^Yhen  these  folds  are  infiltrated,  the  inflammatory  mass 
will  be  felt  posterior  to  the  uterus  crowding  the  organ  to  the  anterior 
part  of  the  pelvis.  Later,  when  resolution  has  taken  place,  contraction 
of  the  ligaments  may  result  in  uterine  displacement.  Post-uterine 
cellulitis  is  examined  best  by  rectal  touch.  If  the  inflammation  has 
progressed  to  the  third  stage — that  is,  to  the  formation  of  an  abscess 
— the  inflammatory  product,  wherever  situated,  usually  will  give  on 
digital  examination  the  sensation  of  a  boggy,  fluctuating  mass. 

The  diagnosis  of  the  effusion  stage  of  pelvic  cellulitis  is  determined 
by  the  presence  .in  the  pelvic  connective  tissue  of  an  inflammatory 


PELVIC  CElJJ'L/riS 


271 


infiltrate  situated  at  some  point  adjacent  to  the  uterus  or  to  the  upper 
part  of  the  vajijina.  This  infiltrate  may  be  observed  with  reference  to 
the  folhnvinj^  cliaracteristics: 

Location.  Immobility. 

Form.  Consistence. 

Relations.  Pain. 

1.  Location. — The  infiltrate  may  be  situated: 

a.  On  one  or  both  sides  of  the  uterus;  if  unilateral,  it  will  crowd 

the  uterus  in  the  opposite  direction  and  depress  the  lateral 
fornix  of  the  vagina  on  the  affected  side. 

b.  Between  the  folds  of  the  broad  ligaments  high  in  the  pelvis, 

with  a  tendency  to  extend  around  the  rectum. 

c.  In  the  post-cervical  connective  tissue,  blocking  up  the  cul- 

de-sac  of  Douglas  and  depressing  the  posterior  fornix  of 
the  vagina — parametritis  posterior. 


Figure  126 


FiGUKE    127 


FiGCRE  126. — Fehling's  three  dh-isions  of  the  pelvic  cavity;  .4,  .-1,  peritoneal  division;  B,  B,  sub- 
peritoneal di\-i5ion;  C,  C.  subcutaneous  di\-ision.  The  levator  ani  muscle  di\-ides  the  subperitoneal 
from  the  subcutaneous  di\'ision. 

Figure  12r. — Parametritis.  Exudate  in  left  subperitoneal  ca^-ity,  crowding  corpus  uteri  to  right. 
Paracolpitis  in  right  subcutaneous  cavit3',  crowding  cervix  uteri  and  vagina  to  left.  This  latter  might 
produce  a  peri-anal  abscess,  followed  by  fistula  in  ano. 


d.  In  the  connective  tissue  between  the  cervix  uteri  and  bladder 

— parametritis  anterior;  very  rare. 

e.  In  all  the  connective  tissue  around  the  uterus — circumuterine 

cellulitis. 
/.  In  the  subcutaneous  region,  as  shown  in  Fig.  123,  crowding 
the  cervix  uteri  and  vagina  to  the  opposite  side  and  having 
a  tendency  to  produce  a  peri-anal  abscess  with  resultant 
fistula  in  ano. 

2.  Form. — The  exudate,  sharply  circumscribed  or  diffu.se,  will  take 
the  shape  of  the  resisting  structures  by  which  it  is  limited,  and  there- 
fore will  vary  in  form  from  a  round  to  an  oblong,  flat,  or  irregular  mass. 

3.  Relations. — The  exudate  may  surround  or  blend  with  neigh- 
boring parts,  such  as  the  rectum,  cervix  uteri,  vaginal  fornix,  and 
bladder. 


272      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

4.  Iminohility. — The  exudate  usually  is  fixed,  the  degree  of  fixation 
increasing  with  the  progress  of  the  disease. 

5.  Comistence. — The  exudate,  according  to  the  location  and  resist- 
ance of  surrounding  structures  and  to  the  composition  of  it,  may 
be  soft  and  elastic,  or  hard  and  less  elastic;  it  may  contain  pus  or 
serum,  and  therefore  may  give  rise  to  fluctuation. 

6.  Pain. — In  most  cases  tenderness  and  pain  are  present. 
Differential  Diagnosis.^ — As  set  forth  in  the  accompanying  table, 

pelvic  cellulitis  has  many  characteristics  in  common  with  the  following 
diseases : 

Pelvic  peritonitis.  Perityphlitic  abscess,  appendicitis. 

Pyosalpinx.  Psoas  abscess. 

Pelvic  hsematocele.  Subserous  myoma. 

The  frequent  association  of  pelvic  cellulitis  with  pelvic  peritonitis 
and  with  salpingitis  may  render  the  differentiation  most  difficult.  It 
is  especially  difficult  when  cellulitis  and  peritonitis  coexist.  Early 
efficient  examination  in  many  cases  of  cellulitis  is  so  painful  as  to  be 
impracticable  without  ansesthesia. 


Pelvic  cellulitis 

1.  Tumor  usually  at  side  of  uterus  with  bulging 
of  one  or  both  lateral  fornices,  seldom  surrounds 
uterus. 

2    Mass  lower  in  pelvis  and  easily  palpated. 

3.  Great  tendency  to  suppuration. 

4.  Uterus  usually  displaced  laterally. 

5.  Not  frequently  so  complicated._ 

6.  Pain  less  severe  and  more  continuous. 

7.  Facial  expression  not  characteristic. 

8.  One  leg  flexed,  seldom  both. 

9.  Nausea  less  frequent. 

10.  Pulse  not  so  rapid;  not  weak. 

Lateral  cellulitis 

1.  Situated  low  and  blocking  vaginal  fornices. 

2.  Usually  not  sharply  outlined,  but  flat  and 
diffused. 

3.  Usually  fixation  of  mass. 

4.  Usually  unilateral. 

Pelvic  cellulitis 
1.   History  of  infection. 


2.  Chill  with  slight  or  high  temperature. 

3.  Slower  development. 

4.  Tumor  usuallj'  hard  until  suppuration. 

5.  Usually  diffuse  mass. 

6.  Exploratorj'  puncture — negative,  serum,  or 
pus. 

Pelvic  cellulitis — right  side 

1.  Onset — pain,   fever,   little   or  no  nausea  or 
vomiting. 

2.  Not  present. 

3.  Low  in  broad  ligament  or  post-uterine  con- 
nective tissue,  easily  felt  through  vagina. 


Pelvic  peritonitis 

1.  Uterus  usually  surrounded  and  fixed  by  an 
infiltrate  with  blocking  up  of  the  vaginal  fornix 
all  around  uterus. 

2.  IMass  rather  high  in  pelvis. 

3.  Tendency  to  suppuration  not  marked. 

4.  Cer-i-ix  usually  fixed  in  median  line  with 
corpus  in  anteversion  or  anteflexion. 

0.  Frequently  results  in  general  peritonitis. 

6.  Pain  severe  and  paroxysmal  in  acute  stage. 

7.  Anxious  facial  expression. 

8.  Both  legs  flexed  on  abdomen. 

9.  Nausea  and  \'omiting  frequent. 
10.  Pulse  rapid  and  weak. 

Pyosalpinx 

1.  Situated  to  one  or  both  sides  of  corpus  uteri, 
or  bound  behind  uterus  in  cul-de-sac  of  Douglas. 

2.  Sharply  outUned;  sausage-shaped. 

3.  Limited  mobility  of  mass. 

4.  Usually  bilateral. 

Pelvic  hcematocele 

1.  History  of  tubal  pregnancy  with  excruciat- 
ing pain,  sudden  and  alarming  signs  of  internal 
hemorrhage. 

2.  No  chill,  fever  slight  or  absent.  May  be 
subnormal  temperature. 

3.  Rapid  development  of  tumor. 

4.  Tumor  soft  and  doughy  or  fluctuating; 
later  hard  and  may  be  elastic. 

5.  Usually  circumscribed  mass. 

6.  Exploratory  puncture — blood. 


Perityphlitic  abscess,  appendicitis 

1.  Onset — pain,  fever,  nausea,  vomiting. 

2.  Tenderness  at  McBurney's  point. 

3.  Exudate  high — surrounds  caecum;   not  felt 
through  vagina.  ■ 


1  These  tabular  statements  of  differential  diagnosis  have  been  adapted  from  numerous  works  on 
gynecology. 


1- El.  VIC  I' E HI  rosins 


273 


Pelvic  cillulilis 

1.  Absent — history  of  non-tubular  infection. 

2.  Absent. 

3.  I'sually  acute  at  first. 

4.  Ordinary  pus  or  serum. 


Pelvic  cellulitis 

1.  Development  more  rapid. 

2.  History  of  infection. 

'■i.   More  diffuse,   not  so  intimately  connected 
with  the  uterus. 


J'noan  ahsress 

1.  Usually  history  and  symptoms  of  tubercu- 
losis. 

2.  Spondylitis. 

3.  No  history  of  acute  inflammation. 

4.  Exploratory  puncture — typical  tubercular 
pus. 

'Suburrous  myoma 

1.  Slow  development. 

2.  No  history  of  infection. 

■i.  Contour  of  tumor — usually  round,  sharply 
circum.scribed;  tumor  intimately  connected  with 
the  uterus. 


Prognosis  of  Pelvic  Cellulitis 

The  prognosis  of  cellulitis  necessarily  is  complicated  with  that  of 
salpin,t2;itis.  The  tube  is  lined  with  mucous  membrane.  Chronic  sup- 
puration of  mucous  surfaces,  even  when  drained,  are  apt  to  be  intract- 
able. On  the  other  hand,  celluUtis  abscess  being  surrounded  by  cellular 
tissue  when  emptied  is  apt  to  close  spontaneously.  Pelvic  cellulitis, 
therefore,  unless  complicated  by  tubal  communication,  either  terminates 
rapidly  by  resolution  with  complete  recovery;  or,  if  suppuration  occur, 
it  empties  spontaneously  or  is  evacuated  by  incision,  and  like  a  furuncle, 
which  it  resembles,  promptly  disappears;  hence  the  cellulitis  abscess, 
unless  of  tubal  origin,  seldom  becomes  chronic,  and  therefore  has  little 
or  no  part  in  the  more  familiar  chronic  pelvic  suppuration  for  which 
the  uterine  appendages  and  sometimes  also  the  uterus  have  to  be 
removed. 

The  very  grave  form  of  pelvic  cellulitis  described  under  Pathology 
as  Erysipelas  Malignum  Internum  of  Virchow,  which  offers  little  hope 
of  recovery  from  the  acute  attack,  may  in  exceptional  cases  go  on  to  a 
very  intractable  form  known  as  chronic  atrophic  cellulitis,  which  offers 
little  encouragement  for  symptomatic  relief  and  none  whatever  for 
anatomical  cure.  Chronic  atrophic  cellulitis  also  may  follow  the  milder 
non-suppurative  attacks. 

Treatment  of  Pelvic  Cellulitis 

The  treatment,  non-surgical  and  surgical,  will  be  given  in  the  follow- 
ing chapter  on  the  Treatment  of  Salpingitis  and  its  Associated 
Lesions — Pelvic  Cellulitis,  Pelvic  Peritonitis,  and  Ovaritis. 


PELVIC   PERITONITIS 


Etiology  of  Pelvic  Peritonitis 

In   pelvic  peritonitis,   sometimes   designated    perimetritis   and  peri- 
salpinr/itis,  infection  usually  reaches  the  peritoneum  from  the  uterine 
or  tubal  mucosa.    Sometimes  the  origin  is  extrapelvic,  as  infection  by 
extension  from  appendicitis  or  from  the  tubercular  lung. 
18 


274     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

Pathology  of  Pelvic  Peritonitis 

The  two  principal  forms  of  peritonitis  are: 

1.  Exudative  peritonitis. 

2.  Plastic  or  adhesive  peritonitis. 

The  two  forms  may  occur  together.  The  plastic  form,  however, 
has  been  observed  with  little  or  no  exudate.  In  addition  may  be  men- 
tioned tubercular  peritonitis  and  pachyperitonitis. 

Exudative  Peritonitis  is  the  result  of  infection  which  does  not  set 
up  adhesions,  and  therefore  does  not  strongly  tend  to  provoke  defensive 
action,  is  more  apt  than  the  plastic  variet}'  to  become  general,  and  for 
this  reason  is  more  dangerous. 

Plastic  or  Adhesive  Peritonitis  is  characterized  by  the  formation 
of  adhesions  which  tend  to  shut  off  and  localize  the  infection  and  to 
prevent  it  from  extending  to  the  general  peritoneum;  the  infection 
thereby  is  limited  not  only  in  extent  and  quantity,  but  its  force  is  spent 
within  narrow  limits,  within  which  the  process  may  be  very  intense, 
and  the  part  may  be  sacrificed  for  the  benefit  of  the  whole.  See  remarks 
on  the  Significance  of  Inflammation  in  Chapter  X.  and  in  the  fol- 
lowing paragraphs.  The  maximum  of  exudate  w^ith  the  minimum  of 
defensive  adhesion  is  dangerous;  conversely,  the  minimum  of  exudate 
with  the  maximum  of  adhesion  is  relatively  safe.  Even  at  the  risk  of 
digression  a  restatement  of  the  significance  of  the  inflammatory  process 
will,  in  this  connection,  have  peculiar  force,  as  follows: 

Extra-uterine  pelvic  infection,  whether  it  passes  from  the  uterus 
by  the  Fallopian  tubes  to  the  peritoneum  by  continuity  of  surface,  or 
by  way  of  the  lymph-channels  or  veins  in  the  pelvic  cellular  tissue, 
may  be  arrested  by  inflammatory  occlusion  of  the  tube  or  by  thrombic 
plugging  of  the  vessels.  In  the  one  case  the  infection  may  be  confined 
to  the  tube  (salpingitis),  in  the  other  to  the  cellular  tissue  around  the 
vessels  (perilymphangitis  or  periphlebitis—^,  e.,  cellulitis).  The  in- 
fection if  not  so  arrested  may  pass  to  the  pelvic  cavity  and  give  rise 
to  peritonitis.  The  inflammatory  process  then  may  localize  itself 
by  setting  up  peritoneal  adhesions  and  forms  a  protective  wall  against 
general  peritonitis.  If  neither  one  of  these  protective  processes  takes 
place,  then  the  infection  speedily  may  involve  the  whole  peritoneum 
and  the  toxins  may  be  increased  rapidly  and  poured  in  fatal  quantities 
from  the  peritoneal  surfaces  into  the  general  circulation. 

We  are  familiar  with  the  profound  depression  of  the  nervous  system, 
the  continued  nausea,  the  anxious  facies,  the  paretic  and  distended 
bowels,  and  the  tympanites,  which  go  to  make  up  the  symptom-group 
of  general  peritonitis.  These  grave  symptoms  of  infection,  so  often 
attributed  wrongly  to  the  inflammatory  process,  are  rather  the  result 
of  the  profound  toxaemia  which  the  inflammation  is  striving  unsuccess- 
fufly  to  shut  off  from  the  general  circulation.  If,  on  the  other  hand, 
a  protective  process  becomes  effective,  the  result  may  be  an  almost 
overwhelming  local  inflammation  which  may  for  the  most  part  be  con- 
fined, so  that  the  infection  will  spend  its  force  within  the  narrow  limits 


PELVIC  PERITONITIS 


275 


of  the  infected  territory.  The  loeahzed  infective  process  may  be  so 
intense  as  to  end  in  pernianont  impairment  of  the  pelvic  nntrition 
and  in  chronic  invahdisni;  l)nt  tlie  inxoKed  tissue  has  taken  the  hrunt 
of  the  attack,  sacrificed  itself,  and  perchance  saved  the  life  of  the 
woman. 

The  exudate  consequent  upon  infection  of  the  peritoneum  may  l)e 
serous  or  jiurulent;  it  may  or  may  not  be  mixed  with  blood.  In  the 
plastic  form  protective  adhesions  often  make  lumierous  partitions 
through  the  infected  j)arts;  hence  several  distinct  collections  of  Huid  may 


Fkjuuk    12s 


Right  and  left  pyosalpinx:  adhesions  to  uterus,  rectum,  and  vermiform  appendix.     Co.  colon;  C, 
caecum:  R,  rectum;  Rt.  right  Fallopian  tube;  Lt,  left  Fallopian  tube;  U.  uterus. 


be  formed.  These  collections  are  sometimes  serous  in  one  part,  purulent 
in  another,  and  hemorrhagic  in  another;  the  whole  may  form  a  tumor 
filling  the  pelvis  and  the  lower  part  of  the  abdomen,  and  having  the 
appearance  and  many  of  the  physical  signs  of  an  ovarian  cyst.  The 
adhesions  may  be  broken  up  gradually  by  movements  of  the  intes- 
tine and  by  absorption,  or  they  may  become  firm  and  permanent; 
hence  the  organs  may  be  matted  strongly  together  with  resultant  dis- 
placement, stenosis,  stricture,  occlusion,  kinking,  embarrassed  peris- 
talsis, and  defective  general  nutrition.    The  fluid  may  be  absorbed  or 


276      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

may  break  into  a  neighboring  organ.  In  the  latter  way  communica- 
tions may  be  formed  between  the  pelvic  cavity  and  the  bowel,  bladder, 
or  vagina.  Sometimes  the  pus  finds  its  way  to  the  cutaneous  surface. 
Accumulations  are  most  frequent  in  the  pouch  of  Douglas.  The  micro- 
scopical findings  show  a  few  round  cells  in  the  serous,  numerous  pus- 
cells  with  a  few  red  blood-corpuscles  in  the  purulent,  and  numerous 
white  and  red  blood-corpuscles  in  the  hemorrhagic  collections. 

Tubercular  Peritonitis  is  of  frequent  occurrence  and  is  very  apt  to  he 
a  part  of  the  general  tubercular  peritonitis  and  usually  is  characterized 
by  small,  sometimes  minute,  pearly  tubercles  or  points  scattered  over 
the  peritoneum. 

The  essential  cause  is  the  bacillus  tuberculosis.  The  source  of  the 
infection  is  usually  tubercular  ulceration  of  the  bowel,  general  tuber- 
culosis, or  localized  tuberculosis  of  the  Fallopian  tubes  or  other  pelvic 
viscera,  or  it  may  extend  from  the  tuberculous  lung  or  other  distant 
organs.    The  disease  is  rarely  primary. 

The  'pathology  differs  from  that  of  ordinary  peritonitis  in  the  following 
particulars : 

1.  The  peritoneum  is  studded  with  miliary  tuberculosis,  of  which 
the  tubercles  may  be  large  and  caseous. 

2.  The  fluid  exudate  (serous,  hemorrhagic,  or  purulent)  appears 
later,  and  in  numerous  places  may  be  encysted. 

3.  The  peritoneal  viscera  usually  are  matted  together  by  adhesions. 

4.  The  mesenteric  glands  may  be  enlarged  and  palpable. 

5.  The  bowel  may  become  perforated  or  obstructed. 
Pachyperitonitis. — Oftentimes    the   peritoneum   is   much   thickened 

by  the  formation  upon  its  surface  of  new  membrane,  which  gives  it  a 
leathery  appearance.  The  vessels  in  this  new  membrane  early  rupture 
with  circumscribed  hemorrhage.    This  is  called  pachyperitonitis. 


Symptoms  of  Pelvic  Peritonitis 

The  symptoms  in  the  acute  stage  vary  within  wide  limits;  may  be 
quite  disproportionate  to  the  gravity  of  the  infection;  may  be  slight 
or  absent;  or  may  include  great  pain,  nausea,  fever,  abdominal  dis- 
tension, retraction  of  the  thighs,  anxious  facies,  and  profound  nervous 
depression.  The  greater  the  tendency  of  the  peritonitis  to  become 
general  the  more  aggravated  will  be  the  symptoms.  The  chronic 
results  of  peritonitis  give  rise  to  great  discomfort,  pain,  and  disturb- 
ance of  function  in  the  pelvis,  especially  about  the  rectum,  uterus,  and 
bladder.  These  symptoms  may  come  largely  from  mechanical  causes, 
such  as  tension  on  bands  of  adhesions  and  pressure  and  traction  upon 
the  inflamed  peritoneum. 

The  distinctive  symptoms  of  tubercular  peritonitis  are:  1,  gradual 
onset;  2,  diffuse,  not  severe,  pain  in  the  abdomen;  3,  febrile  condition 
and  temperature  highest  at  night;  4,  rapid,  often  irregular  pulse,  with 
meteorism;  5,  sweating,  general  malaise,  relapses,  and  remissions. 


OVARITIS  277 

The  sjjccuil  local  .s-/f///.v  of  fiihrrciildr  jtcntointts  are:  1.  eiilaruciiiciit 
of  the  alxloinen;  '2,  local  or  jieiieral  teiuleniess  on  j)ressure;  ;i,  dulness 
on  pereussioii  over  involved  areas. 


Diagnosis  and  Differential  Diagnosis  of  Pelvic  Peritonitis 

The  diagnosis  and  diti'erential  diagnosis  are  given  in  connection  with 
Salpingitis,  Pelvic  Cellulitis,  and  Ovaritis. 


Treatment  of  Pelvic  Peritonitis 

The  treatment  of  pelvic  peritonitis  will  be  found  in  the  following 
chapter. 

OVARITIS 

The  abdominal  end  of  the  Fallopian  tube  is  normally  close  to  the 
ovary  and  communicates  with  it  by  the  tubo-ovarian  ligament.  The 
utero-ovarian  ligament  connects  the  ovary  with  the  uterus.  Between 
the  insertions  of  these  two  ligaments  the  ovary  is  joined  to  the  pos- 
terior fold  of  the  broad  ligament  by  a  broad  base,  the  hilum,  through 
which  pass  the  lymphatics,  blood-vessels,  and  nerves.  Above  the 
hilum  the  ovary  is  covered,  not  by  peritoneum,  but  by  germ  epithe- 
lium, so-called,  which  forms  the  Graafian  follicles  and  from  which  the 
ova  originate.  From  the  above  anatomical  relations  it  is  not  difficult 
to  understand  how  infection  may  reach  the  ovary  from  the  tube  or 
the  uterus.  The  anatomy  of  the  ovary  will  be  considered  further  in 
the  chapters  on  Ovarian  Tumors. 


Etiology  of  Ovaritis 

Adhesions  between  the  tube  and  ovary,  especially  when  recent, 
contain  many  lymph- vessels ;  hence,  bacteria  may  have  a  short  acces- 
sible route  from  the  tube  to  the  ovary.  Accordingly,  inflammation 
of  the  ovary  is  usually  secondary  to  that  of  the  tube.  It  may,  how- 
ever, occur  independently  of  salpingitis  by  extension  from  distant 
organs  or  directly  from  the  peritoneum.  Among  the  bacterial  exciting 
causes  these  may  be  mentioned : 

Gonococcus.  Tubercle  bacillus. 

Colon  bacillus.  Pneumococcus. 

Streptococcus  and  staphylococcus.  Typhoid  bacillus. 


278      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 


Comparative  Pathology  of  Acute  and  Chronic  Ovaritis 


Acute  ovaritis 

1.  Usually  develops  by  extension  from  some 
adjacent  organ. 

2.  Ovary  enlarged,  tense,  and  elastic.  Blood- 
vessels congested.  Punctate  hemorrhages.  Sur- 
face on  cross-section  yellowish  red  and  cedema- 
tous.  Adhesions  form  late  or  not  at  all.  Excep- 
tions: in  gonorrhoeal  ovaritis  adhesions  form 
early. 

3.  Small-cell  infiltration  of  stroma — interstitial 
ovaritis. 

4.  Vessels  congested  and  tortuous. 

5.  Superficial  epithelium  degenerated  and 
desquamated.  Small  hemorrhages,  cellular  in- 
filtration, and  suppuration  about  follicles.  Folli- 
cular epithelium  degenerated.  Liquor  folliculi 
becomes  turbid  from  the  presence  of  round  cells 
and  degenerated  epithelium. 


6.  Infection  of  follicles  from  peritoneum  or 
Fallopian  tube. 

7.  Ovarian  abscess  may  occur;  a,  in  a  corpus 
luteum;  b,  in  the  connective  tissue;  c,  in  the 
Graafian  follicles.  Non-gonorrhceal  abscess 
usually  unilateral,  and  not  associated  with  pyo- 
salpinx:  infection  usually  travels  through  lym- 
phatics in  broad  ligament.  Gonorrhceal  abscess 
usually  bilateral  and  an  extension  of  double 
salpingitis. 

8.  May  rupture  into  peritoneum  or  into  bowel 
or  bladder. 


Chronic  oiaritis 
1.   Usually  develops  from  acute  ovaritis. 


2.  Ovaries  at  first  swollen  and  hard;  later 
surface  uneven,  nodular,  and  cystic.  Cross- 
section  shows  numerous  small  cystic  spaces. 
Tunica  albuginea  hard  and  scar-like.  Adhe- 
sions from  peri-ovaritis  not  uncommon. 


3.  Interstitial  connective  tissue  increased — 
interstitial  ovaritis. 

4.  Same. 

5.  Superficial  epithelium  degenerated  or  ab- 
sent. Small  white  bodies — corpora  allicantes — 
and  hemorrhages  near  follicles.  Ovary  becomes 
smaller  from  contraction  of  connective  tissue. 
Great  numbers  of  follicles  may  be  filled  with 
thick,  turbid,  bloody  fluid  or  may  become  obliter- 
ated. This  follicular  disease  is  known  as  micro- 
cytic degeneration,  and  is  a  common  result  of 
ovaritis;  see  below.  Tunica  albuginea  thickened 
and  may  be  hyaline. 

6.  Same. 


Same. 
See    Tubo-ovarian    Abscess    and     Tubo- 

ovarian  Cyst  under  Salpingitis. 
Tubo-ovarian    abscess    found    by    Martin 

18  times  in  110  ovarian  abscesses. 


8.  Same. 


Symptoms  and  Diagnosis  of  Ovaritis 


Mild  ovaritis  commonly  is  associated  with  catarrhal  endometritis 
and  salpingitis.  Severe  ovaritis  usually  is  complicated  with  pelvic 
peritonitis  and  suppurative  salpingitis. 

Ovarian  abscess  is  difficult  to  recognize;  it  is  characterized  by 
swelling  and  pain,  and  may  give  rise  to  general  sepsis. 

The  following  symptom-group  will  aid  in  the  diagnosis: 

1.  Pain  located  in  ovarian  region,  radiating  to  back,  thighs,  ischiatic 
nerves,  navel,  and  breasts. 

2.  Fever — not  a  constant  nor  reliable  symptom. 

3.  Nausea  and  vomiting — frequent. 

4.  Hemorrhage  from  uterus — not  uncommon. 

5.  In  severe  septic  cases  of  general  pelvic  infection  local  signs  are 
masked. 

6.  Recurrence — usual  in  chronic  cases. 

7.  Painful  defecation  and  frequent  urination. 

8.  Dyspareunia,  hysteria. 

In  chronic  cases  the  ovary  is  less  painful  on  pressure.  The  general 
symptoms — i.  e.,  chill,  fever,  nausea,  and  vomiting — are  absent,  and 
there  is  a  history  of  long-standing  irritation  and  discomfort  in  the 


OVARITIS 


279 


ovarian    region.      Microri/stir    (hficiirnition    is    associated    often    with 
aiiienorrha'a,  (lysnionorrlKra,  and  sterilit\'.    Sir  index. 
The  ijhijtiical  sL(/it,s  of  ovaritis  are: 

1.  Increase  in  size  of  ovary. 

2.  Tenderness  and  sickening  sensation  in  ovary  on  dif,ntal  pressure. 
:].  Displacement  of  ovary  coninion,  usually  backward  to  cul-de-sac 

of  l)ou,i;las,  and  consequent  upon  retrojxjsition  of  uterus. 
4.  Ovary  immobile,  if  adherent;  mobile,  if  not  adherent. 
See  physical  signs  of  salpingitis. 

Diiferential  Diagnosis  of  Ovaritis 


Ovaritis 

1.  In  uncomplicated  ovaritis  inflammatory 
signs  localized  in  ovary  and  sharply  circum- 
scribed. 

2.  Ovary  usually  mobile. 

Ovaritis 

1.  Ovary  enlarged  and  tender. 

2.  Pain  more  or  less  constant. 

3.  History  of  pehdc  infection. 

Ovaritis 

1.  Commonly  bilateral. 

2.  Tends  to  localize  in  pelvis. 

3.  Digestive  disturbances  secondary. 

4.  Absence  of  tenderness  at  McBuriiey's  point. 
.5.  Inflammatory  lesion  deep  in  pelvis. 

6.  Inflamed  organ  recognized  by  size,  form,  and 
relation  to  Fallopian  tube. 


Pelvic  piritonitis  and  cellulitis 

1.  Inflammation  may  involve  whole  pelvis — 
ill-defined. 

2.  Ovary  usually  fixed. 

Ovarian  neuralgia 

1.  Ovary  may  be  normal. 

2.  Pain  inconstant. 

3.  No  such  history. 

Appendicitis  ■ 

1.  Confi.ned  to  right  side. 

2.  Tends  to  involve  abdominal  cavity. 

3.  Primary. 

4.  Usually  present. 

5.  High  in  iliac  space. 

6.  Ovary  often  recognized  by  bimanual  ex- 
amination as  being  separate  and  distinct  from 
inflammatory  area. 


Treatment  of  Ovaritis 

The  treatment  will  be  found  in  the  following  chapter. 


CHAPTER  XX 

TREATIMEXT  OF  PELVIC  IXFLAMMATIOX— SALPINGITIS, 

PELVIC  CELLULITIS,  PELVIC  PERITONITIS,  AND 

OVARITIS 

The  treatment  is  non-surgical  or  surgical. 


NON-SURGICAL    TREATMENT 

The  non-surgical  treatment  of  inflammation  of  the  uterine  appen- 
dages is  general  or  local. 

General  Non-surgical  Treatment 

The  treatment  of  the  milder  adnexal  inflammation,  when  early 
recognized,  is  largely  the  same  as  that  of  the  causative  endometritis. 
Quiet,  frequent  rest,  judicious  active  and  passive  exercise,  avoidance 
of  sexual  excitement,  regulation  of  the  bowels,  nutritious  and  non- 
stimulating  diet,  and  the  prohibition  of  tea  and  coffee  in  neurotic 
cases,  are  among  the  routine  measures.  Repeated  examinations  and 
treatments,  especially  rough  palpation  of  a  sactosalpinx,  may  prove 
dangerous. 

Medical  Treatment. — The  frequent  practice  in  acute  cases  of  lock- 
ing up  the  bowels  and  preventing  peristalsis  by  the  free  use  of  opium 
has  been  abandoned.  On  the  contrary,  rather  active  elimination  through 
the  bowels  and  kidneys  has  become  the  more  accepted  practice.  Pain 
may  be  relieved  by  opium  and  its  derivatives;  but  they  mask  the  symp- 
toms and  check  the  secretions,  and  therefore  in  a  degree  are  contra- 
indicated;  hence  non-constipating  palliatives  usually  are  substituted 
for  opium.  Of  these  aspirin,  chloral  hydrate,  hyoscyamus,  and  sodium 
bromide  are  among  the  more  useful  and  least  objectionable.  The 
codeine  phosphate  repeated  in  half-grain  doses  is  perhaps  the  least 
objectionable  of  the  preparations  of  opium.  Should  the  nervous 
symptoms  predominate  and  demand  the  more  dependable  morphine, 
the  constipating  effect  may  be  overcome  by  the  addition  of  an  equal 
amount  of  podophyllin. 

Elimination  often  is  secured  well  by  means  of  rectal  enemata  con- 
taining magnesium  sulphate,  glycerin,  or  spirit  of  turpentine,  or,  if 
positive  purging  be  required,  by  the  use  of  some  active  cathartic. 
One  may  use  to  advantage  repeated  doses  of  calomel,  one-half  grain 
in  each,  followed  by  Rochelle  salt,  solution  of  magnesium  citrate,  or 
(280) 


TREAT MK\T  OF   PELVIC   I \ FLAM M ATION  281 

some  other  appropriate  saline.  When  the  stomach  will  not  tolerate 
ordinary  eatharties,  a  ^rain  of  ealoinel  may  he  put  n|)on  the  tonj^nie 
everv  hour  until  the  howels  act.  See  use  of  plusosti^min  in  Chapter 
VIll. 

When  the  aeute  symptoms  subside,  absorption  may  be  promoted 
by  the  hot  water  vaj^inal  douche  as  described  in  Chapter  I\'.,  by  the 
internal  use  of  calomel  in  doses  of  ^V  to  j„-  <frain  three  times  a  dav; 
by  saline  laxatives,  sitz-baths,  and  hot  fomentations. 

The  treatment  of  chronic  atrophic  non-suppurative  inflammation  is 
discouragiiif;.  The  estimated  value  of  sea-bathino;,  electricity,  glycerin 
and  tannin  tami)onade,  vaginal  and  rectal  douches,  and  painting  with 
iodine,  varies  widely  with  different  physicians.  The  author  has  not 
found  such  measures  of  great  use. 

There  is  a  form  of  chronic  bilateral  adnexal  disturbance  which 
scarcely  goes  beyond  irritation  and  congestion.  This  is  referred  sub- 
jectively to  the  region  of  the  ovaries  and  sometimes  is  called  ovarian 
neuralgia.  It  is  quite  common  among  nervous,  overwrought  spinsters 
and  girls,  is  associated  usually  with  nervous  irritability,  is  sometimes 
transient,  often  intractable,  seldom  dangerous.  Overwork  and  over- 
excitement,  says  Lawson  Tait,  from  stndy  or  social  requirements,  and 
especially  the  pursuit  of  music,  by  the  physical  strain  of  practice  and 
by  the  power  of  music  to  excite  the  emotions  at  the  developmental 
period  of  puberty,  are  potent,  and,  among  the  higher  classes,  common 
causes  of  ovarian  irritation.  ^Nlany  a  hopeless  neurotic  invalid  may 
in  mature  life  date  her  invalidism  from  mental  and  emotional  strain 
at  the  time  of  puberty.  The  treatment  of  this  indefinite  irritation  should 
be  mainly  hygienic  and  moral — that  is,  rather  regulative  than  medicinal. 
Unsatisfied  sexual  requirements,  conscious  or  unconscious,  demand 
that  the  attention  be  drawn  away  from  the  reproducti\-e  organs.  If 
the  patient  has  reached  the  proper  age,  marriage  may  be  desirable; 
at  least  let  there  be  a  change  of  environment  and  promotion  of  new* 
interests.  A  careful,  all-around  examination  may  show  some  causal 
and  removable  extrapelvic  fault  in  the  patient  or  her  environment. 
There  will  often  be  found  disturbance  of  the  heart,  liver,  or  kidney  or 
intestinal  indigestion,  and  such  disorders  may  explain  the  conditions 
upon  which  the  ovarian  irritation  depends.  There  is  usually  an  asso- 
ciated mild  endometritis,  which  yields,  if  at  all,  to  systemic  treatment. 
The  useless  sacrifice  of  countless  ovaries  in  this  class  of  cases  is  a  reproach 
to  surgery.  [Menorrhagia,  if  associated  with  this  condition,  is  well 
treated  by  ergot,  preferably  given  in  rectal  suppositories,  five  to  ten 
grains,  every  eight  hours  until  the  flow  is  controlled. 

Skene  recommends  for  menorrhagic  and  neurotic  cases  the  con- 
tinued use  of  the  fluidextract  of  hydrastis  in  thirty-drop  doses,  and, 
as  needed  for  nervousness  and  sleeplessness,  twenty  to  thirty  grains  of 
sodium  bromide,  to  be  given  well  diluted  at  bedtime,  and  rep'^ated  if 
necessary.   To  this  may  be  added  calcium  chloride  in  ten-grain  doses. 

The  medical  treatment  not  only  of  the  above  form  of  ovarian  irri- 
tation, but  of  chronic  adnexal  inflammation  in  general,  includes  the 


282      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

judicious  use  of  tonics,  laxatives,  alteratives,  and  hypnotics.  It  must 
conform  to  the  general  principles  of  internal  medicine,  and  differs  in 
no  essential  point  from  the  general  treatment  of  similar  extrapelvic 
disorders. 

Local  Non-surgical  Treatment 

Mechanical  support  for  the  uterus,  if  displaced,  may  open  up  the 
collapsed  uterine  canal,  secure  drainage  of  retained  secretions,  and 
by  overcoming  traction  on  the  blood-vessels  may  relieve  congestion. 

Cold-water  coils  or  the  rubber  ice-bag  applied  to  the  abdomen,  or 
the  application  of  a  large  blister  to  that  part  of  the  hypogastrium 
which  lies  over  the  seat  of  maximum  pain,  and  the  free  use  of  other 
counterirritants  possibly  may  be  serviceable,  especially  in  the  abortive 
treatment  of  acute  cases. 

The  local  treatment  of  chronic  adnexal  inflammation  has  for  its 
chief  object  the  quickening  of  the  pelvic  circulation  and  the  promo- 
tion of  absorption  of  morbid  products.  It  includes:  1,  the  hot-water 
vaginal  douche;  2,  the  vaginal  tamponade  of  lambs'  wool  saturated 
with  glycerin  or  glycerin  and  ichthyol;  3,  the  hot  hip-pack;  4,  elec- 
tricity; 5,  massage. 

The  hot-water  vaginal  douche  and  the  wool  vaginal  tamponade  are 
described  in  Chapter  IV. 

Hot  Hip-pack. — The  application  of  the  hot  hip-pack  is  as  follows: 
Let  an  ordinary  sheet  be  folded  lengthwise  into  several  thicknesses, 
so  that  its  width  will  reach  from  the  umbilicus  to  the  middle  of  the 
thighs.  Let  this  be  made  into  a  roller  bandage,  dipped  in  very  hot 
water,  and  wrung  as  nearly  dry  as  possible,  preferably  by  a  clothes- 
wringer.  Pass  this  bandage  several  times  around  the  pelvis,  so  as  to 
envelop  the  zone  from  the  umbilicus  to  the  middle  of  the  thighs.  Cover 
it  with  a  dry  sheet  and  let  the  patient  lie  in  it  for  thirty  minutes.  It 
is  well,  in  order  to  retain  the  heat  as  long  as  possible,  to  place  between 
the  wet  and  dry  sheet  a  rubber  sheet,  a  rubber  bag  of  hot  water,  or  the 
electric  heating  pad.  The  pack  repeated  daily,  or  twice  daily,  according 
to  the  tolerance  of  the  patient,  is  a  most  efficient  means  of  stimulating 
the  pelvic  circulation,  and  thereby  of  promoting  absorption  of  morbid 
products.  Chronic  constipation,  pelvic  pain,  dysmenorrhoea,  and  other 
functional  disturbances  often  give  way  promptly  under  its  influence. 

Electricity. — The  galvanic  electrode,  even  with  light  dosage,  has 
caused  repeatedly  extensive  destruction  and  cicatricial  contraction  in 
the  genital  tract,  especially  in  the  upper  part  of  the  vagina.  The 
intra-uterine  electrode  is  painful,  often  intolerable,  and  the  occasional 
cause  of  dangerous  infection.  The  faradic  current  is  used  as  a  means 
of  deep  local  massage,  and  the  galvanic  for  its  supposed  resolvent 
effects.  Both  are  said  to  promote  absorption.  The  electrical  treat- 
ment has  proved  itself  neither  in  safety  nor  efficiency  equal  to  the 
promise  of  its  devotees. 

Massage. — General  massage  is  recognized  as  a  measure  of  great 
value. 


TREATMEXT  OF  PELVIC   IXFLAMMATIOX  283 

Local  iimssafi;c  after  the  iiictliod  of  Tliurc  Brandt  is  rccoMimciidcd 
for:  1,  tlio  rc>in()\al  of  iuflaininatory  exudates;  2,  the  hreakiiig  up 
and  stretehiu<;-  of  adhesions;  .'!,  the  restoration  of  function  to  con- 
tracted or  overstretched  Hgaraents;  4,  the  reposition  of  disjilaced 
organs.  The  appHcation  of  local  massage  requires  more  technical 
skill  than  the  physician  would  possess  unless  he  had  received  long 
and  special  preparatory  training.  The  objection  commonly  and 
strongly  urged  against  massage,  that  it  may  excite  sexual  reflexes 
and  produce  erotic  feelings,  is  important;  this  objection,  however, 
provided  that  proper  methods  and  precautions  are  enforced,  need  not 
necessarily,  in  selected  cases,  have  prohibitory  force;  that  is,  properly 
conducted  massage  in  a  suitable  case  should  not  provoke  erotic  feel- 
ings. The  tendency  to  erotic  excitement  would  usually  be  counter- 
acted in  an  inflammatory  case,  by  the  discomfort  which  the  manipula- 
tion necessarily  entails  upon  the  patient;  moreover,  a  subject  of  erotic 
tendencies  would  clearly  be  unfit  for  the  treatment.  Much  depends 
upon  the  individuality  of  the  operator,  and  upon  the  observance  of  an 
inviolable  rule  that  the  left  hand  which  is  in  contact  with  the  external 
genitals  and  especially  the  finger  in  the  vagina  be  kept  perfectl\-  motion- 
less, away  from  the  clitoris  and  against  the  posterior  wall  of  the  vagina. 
The  massage  is  given  entirely  with  the  right  hand  over  the  abdomen. 
Obviously  the  treatment  if  adopted  at  all  should  be  given  by  a  tech- 
nically trained  woman.  The  value  of  the  method  probably  has  been 
overestimated.  Something  of  the  technique  of  the  Brandt  method 
will  be  found  in  the  Chapter  on  the  Treatment  of  Retroversion  and 
Retroflexion. 

Surgical  Treatment 

When  the  disease  has  progressed  to  functional  destruction  of  the 
Fallopian  tube  and  the  formation  of  pyosalpinx,  and  especially  when 
occasional  attacks  of  local  peritonitis  prove  that  the  infection  is  not 
constantly  confined  to  the  tube,  when  the  uterus  is  involved  in  incurable 
metritis  to  the  extent  perchance  that  the  uterine  walls  have  taken  on 
changes  to  resemble  the  walls  of  an  abscess  cavity  or  when  there  is 
pelvic  abscess  imdrained  or  imperfectly  drained,  a  radical  operation, 
even  to  the  removal  of  the  diseased  organs,  may  be  less  dangerous  than 
the  disease,  and,  relatively  speaking,  therefore,  it  may  become  a  con- 
servative measure.  The  inflamed  Fallopian  tube  is  the  storm  centre 
usually  of  the  pathological  indications  for  surgical  interference.  If 
the  tube  is  enlarged  to  the  size  of  the  finger  it  will  seldom  return  to  its 
normal  state  and  functions.  If  there  also  be  suppuration  in  the  pelvis 
due  to  salpingitis,  peritonitis,  cellulitis,  or  ovaritis,  with  great  local 
irritation,  the  indication  for  surgical  interference  is  clear. 

The  operations  to  be  discussed  in  this  chapter  are  the  following: 

Salpingectomy — removal  of  the  Fallopian  tube. 

Odphoredomi/ — removal  of  the  ovary.  Usage  reserves  the  word  ovari- 
otomy to  signify  the  removal  of  ovarian  tumors. 

Hysterectomy — removal  of  the  uterus. 


284      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

Salpingo-odphoredomy  or  odphor-salpingectoviy — the  removal  of  the 
tube  together  with  the  ovary. 

Hystero-oophor-salpiiigectoiny — removal  of  the  uterus  together  with 
the  tube  and  ovary. 

In  place  of  this  cumbersome  nomenclature,  it  would  seem  more 
appropriate  to  use  the  simple  English  expressions — the  removal  of  the 
uterus  w^ith  its  appendages,  or  the  removal  of  the  uterine  appendages. 

In  addition  to  the  above  operations  will  be  considered  also  conserva- 
tive operations  on  the  uterine  appendages. 

Before  taking  up  the  description  of  the  operations  above  mentioned 
it  will  be  profitable  perhaps  to  consider  briefly  the  effect  upon  the  in- 
dividual of  the  removal  of  one  or  more  of  the  reproductive  organs  and 
the  indications  for  such  surgical  interference. 

Effects  of  Removal  of  the  Uterine  Appendages. — The  operation,  if 
thoroughly  performed,  is  followed  generally  by  atrophy  and  consequent 
arrest  of  function  in  the  uterus,  and  the  precipitation  of  the  menopause. 
The  artificial  production  of  this  critical  period  gives  rise  to  phenomena 
quite  similar  to  those  which  characterize  the  natural  menopause,  except 
in  most  cases  menstruation  is  arrested  permanently  at  once.  The  popu- 
lar impression  that  the  operation  unsexes  the  woman  in  a  mental  sense 
or  renders  her  masculine  is  a  mistake.  Patients  frequently  ask  whether 
it  will  result  in  the  growing  of  a  beard  or  the  development  of  a  bass 
voice;  but  no  such  result  has  been  observed.  The  operation  performed 
on  a  young  girl  would  doubtless  arrest  the  intrapelvic  and  some  of  the 
extrapelvic  developmental  processes  of  puberty,  but  development  once 
made  is  permanent. 

The  effect  of  the  operation  upon  sexual  desire  is  variable,  but  prob- 
ably no  more  so  than  that  of  the  natural  menopause. 

The  question  of  insanity  as  a  result  of  the  operation  has  been  raised; 
it  probably  occurs  no  more  frequently  than  after  other  operations  of 
equal  gravity,  probably  not  oftener  than  with  the  natural  menopause. 

The  primary  object  of  the  operation  is  the  removal  of  organs  which 
otherwise  would  be  dangerous  to  life  or  destructive  to  health.  A 
most  important  secondary  result  is  the  arrest  of  physiological  function 
in  the  remaining  uterus.  In  this  connection  it  is  clear  that,  since 
pathology  is  physiology  modified  by  disease,  the  atrophic  changes  in 
the  uterus  consequent  upon  the  operation  may,  at  the  same  time  that 
they  arrest  physiological  processes,  also  put  an  end  to  pathological 
processes.  Especially  is  this  true  in  inflammation  of  the  uterus,  which 
often  is  perpetuated  by  the  constantly  recurring  menstruation.  The 
frequent  disappearance  of  metritis  from  the  atrophic  uterus  verifieti 
a  recognized  principle  that  physiological  rest  may  favor  the  cure  of 
disease.  If  the  uterus  is  healthy  or  the  seat  of  only  mild  catarrhal 
inflammation,  it  usually,  upon  the  removal  of  the  appendages,  will 
pass  rapidly  into  the  atrophic  state,  and  give  no  more  trouble  than 
would  a  uterus  after  the  usual  menopause.  Unfortunately,  however, 
this  very  common  sequence  of  the  removal  of  the  appendages  is  not 
constant.    The  atrophic  process  does  not  always  follow,  or,  if  it  follows, 


TREATMENT  OF  PELVIC  IM-'LA  M  M  ATIOX  285 

may  fail  to  remove  the  infection.  The  infected  uterus  may  be  the 
source  of  i)ernicious  menstruation,  aniountinj;  at  times  to  hemorrhage. 
A  surviving  and  intractable  endometritis  often  gives  rise  to  pnjfuse 
uterine  discharges.  Exhaustive  drains  upon  the  patient's  strength  from 
such  cause  may  destroy  her  resistance  to  disease,  reinforce  the  uterine 
infection,  and  perpetuate  a  group  of  disabling  nervous  symptoms. 

Ovarian  Kxtraris  or  Drsircafrd  Ovaries,  which  may  be  found  in  drug- 
shops  prepared  for  internal  administration,  are  recommended  highly, 
and  are  said  to  give  relief  to  the  disagreeable  symptoms  of  the  meno- 
pause, whether  induced  by  oophorectomy  or  by  nature. 

Should  the  Uterus  be  Removed  with  the  Appendages? — This  ques- 
tion has  been  forced  upon  the  surgeon  by  the  numerous  immediate 
and  remote  failures  which  have  followed  removal  of  the  appendages 
alone.  When  the  appendages  on  one  side  are  healthy,  or  not  sufficiently 
diseased  to  necessitate  their  removal,  and  when  enough  ovarian  tissue 
can  be  left  to  give  hope  that  the  reproductive  function  may  be  preserved, 
the  answer  is  negative.  The  essential  question  is,  What  shall  be  done 
with  the  uterus  when  the  appendages  on  both  sides  have  to  be  removed 
completel>  y  It  may  be  urged  with  considerable  force  that  failure  to 
bring  about  atrophy  of  the  uterus,  arrest  function,  and  to  secure  con- 
sequent relief  from  pernicious  symptoms,  arises  in  many  cases  from 
faulty  technique  in  the  operation.  In  order  to  bring  about  the  most 
satisfactory  results  the  tubes  should  be  removed  not  merely  close  to 
the  uterus,  but  the  entire  tubes,  even  as  they  penetrate  the  cornua, 
should  be  removed  to  the  uterine  mucosa,  and  the  cornual  wounds 
should  be  closed  by  catgut  sutures.  Arthur  W.  Johnstone  and  Lawson 
Tait  have  shown  that  when  every  particle  of  the  appendages  is  removed, 
arrest  of  menstruation,  atrophy  of  the  uterus,  and  a  satisfactory  meno- 
pause, even  in  cases  of  infected  uteri,  are  apt  to  follow.  The  explana- 
tion of  this  is  simple  and  as  follows:  The  thorough  removal  of  the  tubes 
cuts  off  the  ovarian  artery  and  the  supply  from  the  uterine  artery 
at  the  point  of  anastomosis  with  the  ovarian.  As  pomted  out  by 
Johnstone,  it  also  cuts  in  a  similar  way  the  nerve  connections  of  the 
uterus;  hence  the  observed  atrophy  and  arrest  of  function.  The  claim 
of  the  enthusiastic  hysterectomist,  that  when  the  appendages  have 
been  sacrificed  the  uterus  necessarily  becomes  a  pernicious,  continuous, 
disabling,  and  dangerous  source  of  infection,  may,  as  a  universal 
proposition,  be  disregarded.  The  removal  of  a  tube  by  the  ordinary 
stump  and  ligature  method  which  may  result  in  leakage  of  uterine 
secretions  into  the  pelvic  cavity,  properly  has  been  abandoned.  In 
thus  emphasizing  the  necessity  of  complete  removal  of  the  tubes  we 
should  have  clearly  in  mind  not  only  arrest  of  menstruation  but  also 
avoidance  of  stump  exudation  already  mentioned  on  a  previous  page. 

There  is  definite  propriety  in  the  removal  of  an  infected  uterus 
when  the  causative  infection  in  the  endometrium  is  still  overwhelming 
the  pelvic  lymphatics  with  its  septic  supply;  for  the  uterine  infection 
may  continue  to  spread  to  the  peritoneum  even  after  removal  of  the 
appendages.     If  septic  tubes  and  ovaries  are  to  be  removed  it  follows 


286      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

from  the  above  that  the  uterus,  if  septic,  also  may  have  to  be  removed 
in  order  to  cut  off  septic  supply.  Moreover,  unless  the  strength  of  the 
patient  has  been  exhausted  already  by  the  removal  of  the  appendages, 
hysterectomy  may  be  indicated  in  order  to  facilitate  vaginal  drainage. 
In  this  respect  it  presents  manifest  advantages  over  drainage  through 
an  opening  made  for  the  purpose  from  the  pouch  of  Douglas  into  the 
posterior  vaginal  fornix. 

If  in  consequence  of  great  infection  it  becomes  necessary  to  remove 
the  uterus,  the  surgeon  should  avoid  the  half-^ay  measure  of  removing 
only  the  corpus,  for  if  the  cervix  he  left,  it  may  continue  to  he  the  source 
of  persistent  and  pernicious  infection  in  the  adjacent  structures,  even  to 
the  extent  of  filling  the  pelvis  ivith  stump  exudate.  In  fact,  to  reviove  the 
corpus  and  leave  an  infected  cervix  would  he  inexcusahle,  for  the  cervical 
glands,  as  pointed  out  in  the  chapter  on  Endometritis,  are  especially 
adapted  to  the  reception,  the  retention,  and  the  distrihution  of  infection. 

Some  of  the  current  contraindications  to  hysterectomy  ma}^  be  stated 
as  follows: 

1.  The  possibility  that  removal  of  the  uterus,  in  addition  to  removal 
of  the  appendages,  may  disturb  the  moral  and  physical  well-being  of 
the  woman  to  a  greater  extent  than  removal  of  the  appendages  alone. 
However  this  may  be,  since  many  women  have  the  strongest  aversion 
to  hysterectomy,  their  wishes  so  far  as  may  be,  without  harm,  should 
be  respected. 

2.  The  fact  that  removal  of  the  uterus,  especially  by  a  slow  or 
inexpert  operator,  involves  additional  shock  and  danger. 

3.  The  possibility  that  hysterectomy  may  cause  secondary  degenera- 
tive changes  in  the  spinal  cord  or  brain.  This  possible  result  has  been 
observed  as  a  sequel  of  major  operations  in  other  parts,  especially 
those  involving  extensive  injury  to  nerve  structures. 

The  Indications  for   Hysterectomy  are  as  follows: 

1.  The  matting  together  of  the  reproductive  organs  in  one  infected 
mass,  with  pockets  of  pus.  The  difficulty  of  operation  does  not  neces- 
sarily neutralize  this  indication. 

2.  Tuberculosis  of  the  reproductive  organs. 

3.  Complicating  malignant  disease. 

4.  Complicating  uterine  myoma,  which  cannot  be  removed  without 
sacrificing  the  uterus. 

5.  Involvement  of  the  endometrium  in  destructive  inflammation, 
so  that  the  uterine  wall,  itself  strongly  infected,  becomes  virtually  the 
wall  of  a  pus-cavity;  under  these  conditions  the  uterus  is  decidedly  a 
source  of  danger. 

Hysterectomy  without  Removal  of  the  Appendages.— When  the 
appendages  are  firmly  matted  and  bound  together,  and  alniost  in- 
separable from  the  surrounding  structures,  and  their  removal  is  prac- 
tically forbidden  by  the  desperate  risk  of  the  operation,  the  uterus  may 
be  removed  and  the  pus-sacs  freely  opened  and  left  to  drain  into  the 
vagina.  Even  if  some  pus-pockets  are  overlooked,  they  probably 
will  break  sooner  or  later  into  the  wound.     Such  pus-sacs,  whether 


TREATMENT  OF  PELVIC  INFLAMMATION  287 

tubal,  ovarian,  or  parametric,  when  drained  in  this  way,  as  a  rule, 
underf:jo  atroj^liy  and  become  obUterated.  Although  this  partial 
operation  is  only  permissible  for  the  reasons  given  above,  yet  it  has 
been  followed  by  entirely  satisfactory  results.  An  exi)lanation  in  the 
following  paragraph  is  submitted. 

The  removal  of  the  appendages  and  consequent  cutting  off  of  the 
vascular  and  nervous  connections  of  the  uterus  are  followed  usually  by 
atrophy,  cessation  of  function,  and  subsidence  of  disease  in  that  organ; 
conversely,  similar  results  in  the  Fallopian  tubes  and  ovaries  naturally 
should  follow  the  cutting  off  of  their  vascular  and  nerve  connections 
by  the  removal  of  the  uterus.  In  one  recorded  case  of  hysterectomy 
the  remaining  tubes,  however,  became  healthy  and  did  not  atrophy. 
On  the  contrary  they  were,  during  several  years  after  the  operation, 
the  medium  of  apparent  menstruation,  the  menstrual  fluid  passing 
from  them  into  the  vagina.  This  case  speaks  against  the  idea  that  the 
tubes  do  not  participate  in  menstruation.  In  another  case  pregnancy 
occurred  in  the  isthmic  portion  of  the  tube,  with  consequent  hemor- 
rhage into  the  vagina;  the  tubal  opening  was  dilated  and  the  product 
of  conception  curetted  away. 


ROUTES    OF   OPERATION 

There  are  two  recognized  routes  of  incision  for  the  surgical  treat- 
ment of  pelvic  inflammation — the  abdominal  and  the  vaginal.  An 
operation  by  the  abdominal  route  necessitates  abdominal  section,  also 
called  coeliotomy  or  laparotomy.  An  operation  by  the  vaginal  route 
involves  vaginal  section.  It  is  sometimes  necessary  to  combine  ab- 
dominal and  vaginal  section  in  one  operation. 

Operations  by  Abdominal  Section 

The  reader  is  referred  to  Chapters  II.,  VL,  VIL,  and  VIII.  for 
preparatory  treatment,  for  the  technique  of  abdominal  section,  and  for 
the  general  conduct  of  the  operation.  It  is  often  necessary  to  add  to 
this  operation  a  vaginal  section,  hence  the  importance  of  making  in 
the  vagina  and  about  the  vulva  the  same  aseptic  preparations  as 
would  be  made  if  vaginal  section  were  planned  from  the  beginning. 

The  Incision. — Sometimes  the  inflammatory  exudate  has  extended 
through  the  peritoneum  to  the  subperitoneal  structures,  and  so  dis- 
organized and  disguised  the  parts  as  to  render  them  difficult  of  recogni- 
tion. Under  these  conditions  careful  dissection  is  necessary,  in  opening 
the  abdomen,  to  avoid  the  unfortunate  accident  of  opening  directly 
through  the  thickened,  leathery  peritoneum  into  an  adherent  bladder 
or  intestine. 

Use  of  Sponges. — During  an  operation  the  surrounding  peritoneum 
should  be  protected  against  possible  rupture  of  tubal  or  ovarian  ab- 
scesses by  the  free  use  of  sponges  so  placed  as  to  absorb  any  escaping 


288      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

fluid.  In  all  operations  sponges  should  be  of  gauze.  A  special  assistant 
may  be  utilized  for  counting  and  keeping  track  of  sponges  so  that  none 
shall  be  lost  in  the  abdominal  cavity.  Adherent  omentum  which 
may  block  off  the  field  of  operation  should  be  sponged  gently  away 
from  its  attachments. 

Abdominal  Salpingo-obphorectomy, — The  removal  of  the  uterine  ap- 
pendages, i.  e.,  the  tubes  and  ovaries,  if  the  case  be  simple,  with  no 
adhesions,  or  if  the  adhesions  be  few  and  easily  broken,  will  be  rela- 
tively simple.  The  index-finger  of  the  left  hand  finds  the  fundus  and 
posterior  wall  of  the  uterus,  and  then  maps  out  the  diseased  areas  in 
that  region.  The  finger,  starting  from  the  posterior  wall  of  the  uterus, 
sweeps  along  the  posterior  fold  of  the  broad  ligament  on  either  side  and 
examines  the  Fallopian  tubes  and  ovaries.  These  organs,  now  acces- 
sible to  sight  and  touch,  may  be  subjected  to  any  necessary  operation 
or  manipulation.  The  incision,  if  too  short,  may  be  lengthened.  The 
intestine  is  pushed  upward  and  isolated  by  flat  gauze  sponges.  If 
there  are  no  adhesions,  the  appendages  may  be  lifted  gently  up  into 
the  wound  and  examined.  The  surrounding  exposed  parts  should  be 
protected  by  gauze  sponges.  If  removal  of  the  appendages  is  neces- 
sary, the  operation  as  ordinarily  performed  is  as  follows: 

It  is  of  the  utmost  importance  to  remove  every  particle  of  tubal 
tissue,  cutting  it  out  clear  into  the  tissue  of  the  uterus.  Failure  to  do 
this  often  results  in  the  formation  of  stump  exudates  which  perpetuate 
the  evils  of  salpingitis  in  exaggerated  form  and  may  necessitate  addi- 
tional surgery  for  the  removal  of  the  offending  stump. 

Place  a  ligature  on  the  infundibulopelvic  ligament — i.  e.,  on  that 
portion  of  the  broad  ligament  between  the  ovary  and  the  wall  of  the 
pelvis.  Place  another  ligature  on  the  other  end  of  the  broad  ligament 
where  it  joins  the  uterus.  This  ligature  should  not  include  the  F'allo- 
pian  tube.  These  two  ligatures  shut  off  the  ovarian  vessels  and  should 
render  the  remainder  of  the  operation  almost  bloodless.  Grasp  the 
tube,  ovary,  and  adjacent  portion  of  the  broad  ligament  in  the  left  hand, 
and  with  the  scissors  remove  them.  As  these  parts  are  severed  bleeding 
points  may  be  secured  by  temporary  forcipressure.  Fine  catgut  liga- 
tures are  now  placed  upon  any  bleeding  point  between  the  two  ligatures 
already  tied. 

Author's  Reefing  Operation. — This  operation  is  designed  to  shorten 
and  strengthen  the  ligament,  and  to  limit  the  traumatism  and  thereby 
to  secure  the  uterus  against  descent  and  backward  displacement. 
If  there  is  great  tendency  to  descent  or  retroposition,  the  round  liga- 
ments also  may  be  drawn  into  the  broad  ligament  wound  and  shortened 
by  including  them  in  the  broad  ligament  sutures.  The  method  obviates 
the  necessity  of  such  supplementary  operations  as  hysterorrhaphy 
and  vaginal  hysteropexy,  and  is  therefore  especially  applicable  to  cases 
in  which  there  are  great  relaxation  of  the  broad  ligaments  and  conse- 
quent descent  of  the  pelvic  organs.     Figures  129  and  130. 

The  usual  method  of  closing  the  broad  ligament  wound  is  shown 
in  Figure  131.    Observe  the  glover's  stitch  and  method  of  introduction 


TREATMENT  OF  PELVIC  INFLAMMATION 


289 


in  the  whippin<>:  to^etluT  the  cut  ('(!<;(•  of  the  ligaments  on  themselves. 
This  method  is  not  adxised  when  the  li";aments  are  relaxed. 


Fir.iKK    1L".I 

^ 

r 

^ 
t 

1 

I 

1 

,^5 

b 

-^i^^^ 

^ 

m 

fei 

■  -^ 

9 

^ 

/    '  ■        »       ^  '  ^ 

1 

i 

p 

1 

1 

i 

i> 

Removal  of  uterine  appendages,  first  step.  The  tube  has  been  freed  from  the  adhesions  and 
drawn  up  into  the  abdominal  wound ;  one  catgut  ligature  passed  around  the  ovarian  artery  as 
it  runs  through  the  infundibulopelvic  ligament  and  another  as  it  enters  the  uterus.  The  right 
side  shows  the  ligatures  passed,  but  not  tied  ;  the  left  side  shows  them  tied  and  the  tube  and 
ovary  being  excised  by  means  of  scissors. 


Figure   1.30 


Removal  of  uterine  appendages,  second  step.  Ligatures  on  ovarian  vessels  drawn  tight  and 
tied,  and  tubes  and  ovaries  removed.  Any  small  bleeding  points  in  the  cut  surface  between 
the  two  ligatures  that  secure  the  ovarian  arterv  should  be  tied  by  tine  catgut  ligatures.  On  left 
side,  cut  edge  of  broad  ligament  being  closed  by  author's  reefing  suture  in  such  a  way  as  to  fold 
cut  edge  on  itself  and  thereby  strengthen  and  shorten  the  ligament.  On  right  side  closure  of 
ligament  complete. 

19 


290      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

Figure  132  illustrates  removal  of  an  ovary  without  sacrifice  of  the 
tube.  Figure  133  shows  removal  of  a  Fallopian  tube  without  sacrifice 
of  the  ovary. 

The  Difficulties,  Complications,  and  Dangers  of  salpingectomy  may 
be  small  or  may  be  so  great  as  to  make  it  one  of  the  most  formidable 
in  surgery.  The  special  technique  to  meet  the  varied  conditions  turn 
usually  upon  the  presence  or  absence  of  pus,  adhesions,  or  hemorrhage 
upon  the  necessity  for  drainage,  upon  possible  injury  to  the  intestine, 
ureter  or  bladder,  and  last  but  not  least  upon  the  question  of  whether 
the  uterus  together  with  its  appendages  should  be  removed. 

Figure  131 


Removal  of  uterine  appendages,  final  step.    Showing  the  glover's  stitch  and  the  method  of  introduction. 


Technique  in  Pus  Cases. —Although  the  pus  in  chronic  pyosalpinx 
is  usually  sterile,  it  is  not  always  so;  hence  it  is  safer  to  proceed  on 
the  supposition  that  all  pus  or  other  fluid  is  infections,  and,  if  possible, 
therefore  to  enucleate  the  sac  without  breaking  it.  Aspiration  of  a 
part  of  the  fluid  from  a  very  tense  tube  may  decrease  the  risk  of 
rupture.  On  the  contrary  contact  of  the  pus  of  a  ruptured  tube  with 
the  peritoneum  may  have  no  serious  results,  for: 

1.  The  fluid  may  be  sterile,  and  therefore  innocent. 

2.  Even  though  infectious,  if  carefully  sponged  out,  the  residue 
of  septic  matter,  now  much  reduced,  may  be  taken  up  readily  by  the 
peritoneum  and  thrown  off  by  the  organs  of  elimination.  The  capacity 
of  the  peritoneum  to  absorb  and  eliminate  such  matter  sometimes  is 


TREATMENT  OF  PELVIC   I \ FLAM M AVION 


201 


FlliURE     l.iJ 


liemoval  of  ovary  ;  tube  being  normal,  is  not  removed. 
Figure   133 


Removal  of  Fallopian  tube ;  ovary  being  normal 


292      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

very  great.  The  conditions,  however,  under  which  it  does  or  does  not 
do  so  are  not  fully  known.    See  Chapter  VIL,  on  Drainage. 

The  coexistence  of  pyosalpinx  and  a  communicating  parametric 
abscess  clearly  renders  the  clean  enucleation  of  the  pus-sac  impossible. 
After  removal  of  such  a  tube  the  parametric  abscess  cavity  will  be 
in  direct  communication  with  the  pelvic  cavity,  and  this  will  necessitate 
a  free  opening  from  the  cul-de-sac  of  Douglas  into  the  vagina  and 
effective  gauze  drainage  by  that  route.  If  possible,  the  general  abdomi- 
nal cavity  should  be  shut  off  by  stitching  peritoneum  over  the  abscess- 
wall  (technique  of  Figure  185).  If  there  be  a  parametric  abscess  pure 
and  simple,  without  tubal  or  other  connections,  the  pus  should  be  evacu- 
ated and  drained  preferably  by  the  vaginal  rather  than  by  the  abdominal 
route.    Even  with  tubal  involvement  the  vaginal  route  has  advantages. 

When  the  pelvic  viscera  are  matted  together  wdth  strong  and  ex- 
tensive adhesions,  including  a  great  quantity  of  inflammatory  infil- 
trate and  pus,  hysterectomy  and  vaginal  drainage  may  be  necessary 
in  addition  to  the  removal  of  the  uterine  appendage;  such  operations 
furnish  much  of  the  mortality  in  oophoro-salpingectomy.  The  danger 
may  be  so  great  as  even  to  prohibit  the  radical  operation  and  to  require 
instead  the  more  conservative  measure  of  simple  incision  and  drainage 
by  the  vaginal  or  abdominal  route.  Sometimes  the  adhesions  between 
the  visceral  peritoneum  covering  the  abscess  and  the  parietal  peri- 
toneum through  which  the  abdominal  incision  is  made  are  so  extensive 
that  the  operator  may  find  his  way  directly  into  the  pus-cavity  without 
exposure  of  the  general  peritoneum.  In  such  a  case  it  is  wise  not  to 
attempt  removal  of  the  appendages,  nor  even  to  make  a  complete 
diagnosis,  but  rather  to  locate,  incise,  and  drain  the  pus-cavity.  A 
more  radical  operation  may  be  made  later,  if  necessary.  Upon  opening 
the  abdomen  one  may  locate  a  pus-sac  adherent  to  some  part  of  the 
abdominal  wall  at  a  distance  from  the  incision :  it  might  then  be  good 
surgery  to  close  the  first  incision  and  make  another  through  the 
abdomen  or  vagina  directly  into  the  sac.  The  abscess  could  then  be 
evacuated  without  contamination  of  the  peritoneum. 

The  indications  and  technique  of  sponging  out  or  otherwise  cleansing 
the  peritoneal  cavity,  and  the  indications  and  modes  of  abdominal 
drainage  and  the  toilet  of  the  peritoneum,  are  set  forth  under  the 
General  Principles  of  Peritoneal  Surgery,  in  Chapters  VI.  and  VII. 

Technique  in  Adhesions. — Strong  and  extensive  adhesions  are  among 
the  most  common  difficulties  in  the  freeing  of  such  hopelessly  diseased 
organs  as  judicious  surgery  marks  for  removal.  If  adherent  omentum 
is  in  the  way,  it  may  be  separated  gently  wdth  the  sponge — that  is, 
sponged  off  from  its  attachments.  The  first  objective  point,  as  in  the 
simple  cases,  is  the  fundus  and  the  posterior  wall  of  the  uterus.  From 
this  point  the  finger  searches  out  the  diseased  uterine  appendages 
on  either  side  and  recognizes  their  relations  to  adjacent  structures. 
An  ovary  or  tube,  even  though  imbedded  in  apparently  inseparable 
adhesions,  may  often  be  shelled  out  with  relative  ease  if  the  weaker 
lines  of  cleavage  can  be  found  and  made  the  starting-points  of  enucle- 


TREATMEXT  OF  I'KLVlr  IXFLAMMATION  293 

ation.  Li't  the  tij)  of  the  index  and  middle  Hn<,a'r.s  oi  the  left  hand 
search  for  sulci  between  the  diseased  ai)i)endaf,a's  and  the  adherent 
surfaces.  Follow  points  of  least  resistance  so  long  as  the  separation 
does  not  require  undue  force;  then  look  for  other  such  points.  The 
finger  advances  with  gentle  firmness,  using  the  side-to-side  and  to-and- 
fro  motion,  until  by  pressing  here  and  there,  and  by  j>inching  the  ad- 
herent structures  apart,  the  outlines  of  the  diseased  organs  are  made 
clearer  and  clearer.  13y  this  means  they  finall\-  are  isolated  and  brought 
up  into  the  wound.  The  technique  of  removal  is  then  the  same  as  for 
non-adherent  appendages. 

Technique  in  Hemorrhage.^During  the  enucleation  it  is  not  well 
to  stop  for  minor  bleeding-points.  Let  the  organs  be  isolated  from 
the  bed  of  adhesions  as  rapidly  as  safety  will  permit.  Always  keep 
sponges  packed  around  to  control  hemorrhage  by  pressure  and  to 
absorb  blood,  pus,  or  serum.  When  the  appendages  are  cut  off  and 
the  ordinary  ligatures  applied  the  bleeding  usually  will  have  ceased. 
If  not,  pack  hot  sponges  firmly  against  the  bleeding  surfaces,  fre- 
quently changing  them  to  prolong  the  heat.  If  bleeding  is  not  con- 
trolled by  prolonged  hot-sponge  pressure,  and  ligature  of  the  ovarian 
vessels,  and  the  bleeding-points  cannot  be  secured  by  isolated  ligatures, 
it  is  better  not  to  prolong  the  operation  by  temporizing,  but  to  insure 
haemostasis  by  immediate  ligature  of  the.  uterine  arteries,  and  if  need 
be  by  removal  of  the  uterus.  The  ligature  is  applied  in  the  same 
manner  as  for  abdominal  hysterectomy. 

Technique  Required  in  Drainage. — Usually  drainage  should  be  if  at  all 
not  through  the  abdominal  wound,  but  through  the  vagina,  an  opening 
from  the  pouch  of  Douglas  into  the  vagina  having  been  made  for  the 
purpose.     See  Chapter  on  Drainage. 

Technique  in  Intestinal  Opening. — Mention  has  been  made  of  the 
breaking  through  and  discharge  of  the  contents  of  a  pus-tube  into  an 
adherent  intestine.  The  enucleation  of  such  a  tube  necessarily  would 
leave  an  opening  in  the  intestine.  Some  provision  then  must  be  made 
to  keep  the  contents  of  the  bowel  from  escaping  through  this  opening 
into  the  free  abdominal  cavity.  There  are  several  possible  plans  of 
procedure : 

1.  If  the  opening  is  small,  accessible,  and  not  friable,  it  should  be 
closed  with  sutures  and  treated  according  to  the  requirements,  with 
or  without  abdominal  drainage. 

2.  If  the  opening  is  accessible  and  the  loss  of  bowel-wall  so  great 
that  repair  with  sutures  would  destroy  the  permeability  of  the  bowel, 
the  indication  is  for  resection  or  for  stitching  the  opening  into  the 
abdominal  wound,  and  making  thereby  an  artificial  anus.  Unless 
contraindicated  by  the  exhausted  condition  of  the  patient,  resection 
would  be  preferable,  for  if  the  artificial  anus  did  not  close  spontane- 
ously resection  would  have  to  be  made  subsequently. 

3.  If  the  opening  is  so  deep  in  the  pelvis  as  to  be  inaccessible  or 
the  patient  is  too  exhausted  to  permit  suture,  the  territory  around  the 
fistula  may  be  quarantined  from  the  general  peritoneum  by  means  of 


294      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

gauze  packing.  The  gauze  may  be  brought  out  through  the  abdominal 
wound,  or  if  the  fistula  is  deep  in  the  pelvis,  it  is  better  to  pass  the  gauze 
drain  into  the  vagina  through  an  opening  made  for  the  purpose  and  to 
close  the  abdominal  wound.  Adhesions  will  form  in  a  few  hours  around 
the  packing  and  thereby  shut  off  the  leaking  bow^el  from  the  gen- 
eral peritoneum.  I  have  successfully  treated  several  cases  by  this 
method. 

4.  If  the  fistula  is  too  large  for  suture,  the  parietal  peritoneum  may 
be  made  to  take  the  place  of  the  lost  intestinal  wall.  This  will  require 
the  edges  of  the  fistula  to  be  united  to  the  abdominal  wall  by  means 
of  a  plate  of  decalcified  bone  or  other  absorbable  material.  The 
plate  should  have  small  perforations  one-sixth  of  an  inch  apart  all 
around  near  its  outer  edge;  it  is  placed  inside  the  intestinal  opening, 
and  through  this  perforation  the  margin  of  the  bowel  may  be  stitched 
to  the  parietal  peritoneum.  The  sutures  should  transfix  the  bowel- 
wall  and  the  abdominal  wall  and  be  tied  on  the  skin,  thereby  approxi- 
mating serosa  to  serosa. 

5.  The  following  case  is  illustrative  and  instructive.  In  an  operation 
at  St.  Luke's  Hospital,  Chicago,  a  large  friable  pus-tube  was  in  com- 
munication with  the  bowel  at  two  points.  After  enucleation  there  was 
a  fistula  too  large  to  be  closed  at  each  of  these  points.  The  bowel- 
wall  surrounding  the  fistula  was,  moreover,  extremely  thickened  and 
friable.  The  first  impulse  was  to  resect  the  bowel  at  each  point  of 
injury.  Instead  of  this  most  formidable  operation,  however,  the  fol- 
lowing plan  was  adopted  successfully:  The  two  openings  were  brought 
together  and  united  by  three  rows  of  fine  continuous  silk  sutures,  the 
fistulse  thereby  being  utilized  as  openings  for  an  intestinal  anastomosis. 
The  abdominal  wound  was  closed  with  only  a  slight  gauze  drain  ex- 
tending from  its  upper  angle  to  the  immediate  neighborhood  of  the 
intestinal  sutures.  This  drain  was  removed  on  the  fourth  day.  The 
result  was  complete  recovery.  So  far  as  the  writer  is  informed,  this 
principle  has  never  been  used  in  a  case  like  the  above. 

Technique  in  Accidental  Wounds  of  the  Ureter. — In  the  course  of  a 
pelvic  operation  the  ureter  may  be  cut  accidentally  in  the  longitudinal 
direction,  or  partially  severed  in  the  transverse  direction,  or  completely 
divided.    Then  one  of  the  following  operations  will  be  indicated. 

Ureterorrhaphy. — For  Incomplete  Division  of  the  Ureter. — If  a  ureter 
opened  in  the  longitudinal  direction  is  closed  by  a  line  of  union  running 
in  the  same  direction,  there  will  be  danger  of  stricture  at  the  point  of 
closure.  To  prevent  this,  the  line  of  union  should  run  at  right  angles 
to  the  line  of  incision — that  is,  transversely^  as  suggested  by  Fenger, 
who  deliberately  opened  a  strictured  ureter  longitudinally  and  then 
increased  the  caliber  by  closing  it  transversely.  In  case  of  partial 
transverse  division,  Van  Hook  suggests  that  a  longitudinal  incision  be 
made  directly  across  the  middle  of  the  transverse  cut  at  right  angles 
to  it  and  twice  as  long  as  the  diameter  of  the  tube.  The  sharp  angles 
should  then  be  rounded  off  with  scissors  and  the  wound  sutured,  as 
described  above  for  longitudinal  wounds. 


TliEATMEXT  OF   PELVIC   IXFLAMMATIOX  295 

For  Complete  Divisioti  i>f  the  inter  one  of  the  follouing  procedures 
trill  be  rcfjiiired: 

Insertion  into  the  Bladder. — It'  tlie  part  above  the  injury  can  be  drawn 
down  to  tlie  blatlder  witliout  undue  traction,  it  may  be  inserted  into 
the  bhidder  tlirough  an  oj)ening  made  for  tlie  j)urpose  and  fixed  there 
by  means  of  fine  sutures. 

Lateral  Anastomosis. — If  the  part  above  the  injury  will  not  reach 
the  bladder,  it  may  be  inserted  into  the  lower  frajjment  after  th.e 
method  of  \'an  Hook.     This  operation  is  shown  in  Figure  134. 

Figure  134 


Lateral  anastomosis  of  the  ureter. 

A.  First  step:  natural  size.  Showing  the  fragment  toward  the  bladder  tied  and  slit  longitudinally 
for  the  reception  of  the  upper  fragment.  The  two  ends  of  a  fine  silk  or  chromic  catgut  suture  have 
been  passed  through  the  ureteral  wall  near  the  end  of  the  upper  fragment  from  within  outward.  Two 
fine  needles  on  this  suture  are  transfixing  the  wall  of  the  lower  fragment  preparatorj-  to  drawing  the 
end  of  the  upper  fragment  into  the  longitudinal  slit. 

B.  Second  step:  natural  size.  The  upper  fragment  has  been  drawn  into  the  longitudinal  slit  in 
the  lower  fragment  and  made  fast  by  t\-ing  the  suture:  in. order  to  insure  security  against  leakage. 
one  more  similar  suture  should  be  placed  and  tied  on  the  opposite  side,  and  a  few  verj-  fine  interrupted 
sutures  should  be  introduced  quite  superficially  around  the  anastomotic  union.  The  anastomosis 
thus  completed  should  be  covered  by  stitching  omentum  or  some  other  peritoneal  structiire  over  it. 
If  there  is  no  apparent  leakage,  the  abdonoinal  wound  may  be  closed  without  drain. 

T'reterocystostomy  by  Bladder  Diverticuhrm. — For  cases  in  which 
the  ureter  cannot  be  made  to  reach  the  bladder,  Van  Hook  proposes 
that  the  bladder  be  extended  to  the  ureter  by  dissecting  a  flap  from 
the  anterior  vesical  wall  and  reflecting  it  upward  to  meet  the  ureter 
in  such  a  manner  as  to  form  a  tubular  diverticulum  from  the  bladder 
to  the  ureter. 

Ureteral  Fistula  to  the  External  Surface. — If  for  any  reason  none 
of  the  above  operations  is  practical,  the  ureter  should  be  brought  out 
through  the  lower  end  of  the  abdominal  wound  at  the  nearest  possible 
point  to  the  bladder,  so  that  the  urine  may  discharge  temporarily  to 
the  external  surface  until  connection  with  the  bladder  can  be  attempted, 
for  example,  as  follows: 

Xephrectomy. — \Mien  the  ureter  cannot  be  connected  with  the 
bladder,  the  only  alternative  may  be  to  remove  the  kidney  on  the 
affected  side. 

Technique  in  Hysterectomy. — If  in  the  course  of  the  removal  of  the 
uterus  appendages  it  becomes  necessary  to  remove  the  uterus  also, 
the  danger  will  increase  rapidly  with  delay.  The  operator  therefore 
should  proceed  without  hesitation  and  consequent  loss  of  time.  See 
later  paragraphs  in  this  chapter  on  the  indications  for  the  removal 
of  the  uterus  with  the  appendages.  The  principle  and  technique  of 
the  operation  differs  in  no  essential  respect  from  those  of  complete 


296      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

hysterectomy  for  myomata — described  in  the  Chapter  on  Treatment 
of  Myoma. 

Opening  and  Draining  of  Abscesses. — Pelvic  abscesses  whether  from 
celluHtis  or  tubal  origin  ordinarily  are  best  opened  through  the  vagina, 
but  if  they  are  manifestly  pointing  toward  the  abdominal  wall  and  par- 
ticularly if  the  abscess-wall  is  in  such  a  w^ay  adherent  to  the  abdominal 
parietal  peritoneum  that  an  incision  may  be  made  directly  into  it 
without  invading  the  general  peritoneal  cavity,  then  the  abdominal 
route  of  incision  is  clearly  the  one  of  election.  See  later  paragraphs 
on  vaginal  incision  and  drainage  in  this  chapter. 

Operations  by  Vaginal  Section 

The  maxim  that  every  peritoneal  section  should  begin  as  an  ex- 
ploration holds  true  as  well  for  vaginal  as  for  abdominal  section. 
Thorough  sharp  curettage  and  cleansing  of  the  endometrium  are 
essential  preliminaries.  The  object  is,  first,  to  remove  the  original 
source  of  infection;  second,  to  prevent  infection  of  the  peritoneum 
from  the  uterus  during  the  operation.  Vaginal  section  according  to 
the  indication  is  made  either  anterior  or  posterior  to  the  uterus,  or 
both  anteriorly  and  posteriorly. 

Posterior  Vaginal  Section 

The  posterior  incision  is  made  close  to  the  uterus,  between  the  cervix 
uteri  and  the  rectum,  from  the  post-vaginal  fornix  into  the  pouch  of 
Douglas.     The  steps  of  the  operation  are  as  follows: 

1.  The  patient  is  to  be  placed  in  the  dorsal  position  and  the  vaginal 
portion  of  the  cervix  exposed  by  Simon's  retractors. 

2.  A  semicircular  incision,  large  enough  to  admit  two  fingers,  is 
made  directly  behind  the  uterus  in  the  line  of  the  uterovaginal  attach- 
ment, with  blunt-pointed  scissors  curved  on  the  flat,  the  point  being 
directed  toward  the  uterus  and  the  cervix  being  drawn  down  by  the 
vulsellum  forceps. 

3.  The  loose  cellular  tissue  back  of  the  cervix  between  the  vagina 
and  the  pouch  of  Douglas  is  stripped  back  off  from  the  cervix  by  the 
blunt  point  of  the  scissors,  by  the  handle  of  a  scalpel,  or  by  the  finger, 
until  the  peritoneum  is  reached. 

4.  The  peritoneum  is  divided  close  to  the  uterus  by  a  snip  of  the 
scissors.  The  closed  scissors-points  are  now  passed  through  into 
the  pouch  of  Douglas  and  the  opening  is  dilated  by  spreading  the 
blades,  and  if  necessary  enlarged  still  farther  by  careful  cutting  with 
the  scissors  or  by  tearing  with  the  fingers. 

5.  The  index  and  middle  fingers  of  the  left  hand  now  are  intro- 
duced into  the  pouch  of  Douglas  and  the  pelvic  cavity  is  explored 
digitally.  If  sufficient  room  has  not  been  gained,  a  perpendicular 
incision,  beginning  in  the  middle  of  the  posterior  border  of  the  one 
already  described  and  running  toward  the  rectum,   may  be  made. 


THEATMEXT  OF   I'EI.VIC   J  X /LA  M  M  ATIO.X  297 

In  cutting  down  toward  the  bowel  the  left  intlex-hnijer  in  the  rectum 
should  l)e  used  as  a  guide.  This  finger  then  is  withdrawn,  disinfected, 
and  with  a  fresh  rubber  glove  reintroduced  into  the  pouch  of  Douglas; 
the  right  hand  is  placed  t)ver  the  hypogastrium  behind  the  pubes, 
and  the  examination  is  made  precisely  as  in  ordinary  bimanual  palpa- 
tion, but  with  a  distinct  advantage — i.  e.,  the  palpating  finger  is  in 
direct  contact  with  the  uterus  and  its  appendages. 

Posterior  vaginal  section  is  not  well  adapted  to  removal  of  the  appen- 
dages; it  is,  liowever,  specially  applicable  to  the  incision  and  drainage 
of  pelvic  pus-cavities.  These  cavities  may  be  in  the  tubes,  ovaries, 
or  pelvic  connective  tissue.  See  Incision  and  Drainage  of  Pelvic 
Abscesses  in  this  chapter. 

Anterior  Vaginal  Section 

Peritoneal  section  anterior  to  the  uterus — ?'.  e.,  between  the  uterus 
and  bladder — renders  the  uterus  and  its  appendages  more  accessible 
to  extensive  radical  operation  than  posterior  section,  but  less  acces- 
sible than  abdominal  section.  The  technique  is  similar  to  that  of  pos- 
terior section,  and  is  as  follows: 

The  patient  is  placed  in  the  dorsal  position,  and  the  bladder  being 
empty  the  cervix  is  exposed  by  Simon's  retractors.  The  cervix  is  seized 
with  vulsellum  forceps  and  drawn  toward  the  vulva.  A  transverse 
semicircular  incision  close  to  the  uterus,  in  a  line  with  the  utero- 
vaginal attachment,  is  made  with  scissors  through  the  anterior  vaginal 
fornix;  or,  instead  of  this,  the  incision  is  made  in  the  longitudinal 
direction  in  the  median  line  through  the  anterior  vaginal  wall  from  the 
anterior  wall  of  the  cervix  toward  the  bladder.  The  latter  incision  is 
advantageous,  because,  without  great  care,  especially  if  the  cervix  is 
small,  the  transverse  incision  may  injure  the  ureters.  In  making  the 
longitudinal  incision,  the  operator  should  not  only  draw  the  cervix 
uteri  well  down,  but  also  make  strong  downward  traction  on  the  anterior 
vaginal  wall.  This  is  done  with  a  tooth-forceps  attached  to  the  wall 
between  the  cer\dx  uteri  and  the  urethra.  If  the  longitudinal  inci- 
sion give  insufficient  room,  it  may  be  supplemented  by  the  transverse. 
The  combined  longitudinal  and  transverse  cuts  have  the  shape  of  the 
letter  T.  They  are  shown  in  Figure  135,  and  in  the  illustrations  of  the 
surgical  treatment  of  myomata. 

The  uterus  now  is  dra'^m  strongly  for«-ard,  and  the  structures  ad- 
jacent to  its  anterior  wall  are  stripped  oflF,  keeping  close  to  the  uterus, 
as  described  above  for  posterior  section.  As  the  bladder  is  being  sep- 
arated from  the  uterus  it  is  held  up  out  of  the  way  by  an  anterior 
retractor  or  the  finger.  ^Mien  the  peritoneum  comes  into  view,  it  vrill 
be  recognized  as  a  thin,  translucent  membrane  reflected  from  the 
uterus.  A  sound  passed  into  the  bladder  will  guard  against  cutting 
that  organ  for  the  peritoneum.  The  peritoneum  is  snipped  with 
blunt-pointed  scissors.  The  opening  thus  made  into  the  pelvic  cavity 
is  enlarged  by  introducing  the  two  index-fingers  and  tearing  laterally, 


298      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

and,  if  necessary,  by  careful  cutting  with  the  scissors.  During  the  sep- 
aration of  the  bladder  from  the  uterus  a  sound  in  the  uterine  canal 
may  be  useful  as  a  guide. 

The  corpus  uteri  may  now,  if  adhesions  do  not  prevent,  be  seized 
with  vulsellum  or  bullet-forceps  and  the  fundus  drawn  into  the  vagina. 
If  there  be  adhesions,  they  may  be  loosened  with  the  left  index-finger 
introduced  over  the  fundus  uteri,  the  corpus  being  at  the  same  time 
drawn  more  and  more  into  the  vaginal  opening.  The  Fallopian  tubes 
and  ovaries  follow  the  corpus,  and  may  be  subjected  to  examination 
and  any  necessary  operation. 

Figure  135 


L 


Lines  of  anterior,  posterior,  and  lateral  incisions  in  vaginal  section:     A,  anterior  incision;  P,  posterior 
incision;  L,  L,  lateral  incisions. 


The  anterior  incision,  except  for  drainage  of  pus-cavities,  is  prefer- 
able to  the  posterior.  It  involves  less  danger  of  post-uterine  adhesions, 
which  may  result  in  fixation  of  the  retro  verted  or  retroflexed  uterus. 
Moreover,  it  offers  by  anterior  vaginal  fixation  a  cure  for  the  retro- 
malpositions.  See  Treatment  of  Ptetroversion  and  Retroflexion  by 
Vaginal  Fixation.  In  some  cases  intrapelvic  disease  is  rendered  more 
accessible  by  the  combined  anterior  and  posterior  incisions. 

Vaginal  Salpingo-obphorectomy. — The  removal  of  the  vterine  apyen- 
dages  by  anterior  vaginal  section  does  not  differ  materially  in  technique 


TREATMENT  OF   I'KIAIC   I S  FLAM  M  AT  ION  299 

from  removal  l)y  alxloiniiial  section.  Ilu'inostasis  may  he  secured  hy 
the  usual  lii^ature  elose  to  tlie  uterus  or  hy  ruiminff  sutures  in  the  hroad 
hgament.  To  bring  the  appendages  into  full  view  may  require  firm 
traction,  and  the  uterus  may  have  to  be  drawn  from  side  to  side.  Liga- 
tion of  the  infundibuloi)elvic  ligament,  which  controls  the  ovarian 
vessels,  is  often  ilifHcult,  st)metimes  imj)ossil)le.  Sometimes  the  broad 
ligament,  if  short,  tense,  and  adherent,  cannot  be  reached  through  the 
vagina.  In  such  case  it  would  be  safer  to  abandon  the  vaginal  and  resort 
to  the  abdominal  route.  If  there  is  difficulty  in  returning  the  uterus 
enlarged  by  congestion,  from  torsion  of  the  ligaments,  the  Simon 
retractor  may  be  used  in  the  manner  of  a  shoe-horn,  and  the  uterus 
slid  in  on  the  smooth  blade. 

The  blood-clots  having  been  sponged  out  and  all  i)leeding-points 
secured,  the  wound  is  closed  as  follows:  The  peritoneal  margins  are 
drawn  down  and  approximated  by  means  of  pressure-forceps.  They 
then  are  whipped  together  with  a  running  fine  catgut  suture.  The 
suture  is  continued  as  a  buried  suture  to  unite  the  vesical  to  the  uterine 
surfaces  of  the  wound,  and  finally  as  a  running  suture  to  close  the 
vaginal  margins.    The  vagina  is  packed  lightly  with  aseptic  gauze. 

Vaginal  Hysterectomy. — Abdominal  hysterectomy  for  pelvic  infection, 
in  the  author's  judgment,  is  much  more  frequently  the  operation  of  choice 
than  vaginal  hysterectomy.  The  vaginal  operation,  hoicever,  has  recogni- 
tion in  the  surgery  of  infectious  and  malignant  disease  of  the  uterus  and 
of  complete  descent  of  the  uterus;  it  is  here  described  fully,  with  extended 
illustrations. 

In  the  vaginal  operation  for  the  removal  of  the  uterus  two  principal 
methods  of  hsemostasis  are  in  use: 

Ha?mostasis  by  ligature. 

Htemostasis  by  forcipressure. 

Vaginal  Hysterectomy  with  Haemostasis  by  Ligature. — The  techniciue 
of  the  operation  is  as  follows:  The  patient  is  placed  in  the  lithotomy 
position;  the  vulvovaginal  surfaces  are  thoroughly  disinfected — ■ 
Chapter  II.,  the  cervical  canal  is  dilated;  and  the  endometrium  curetted, 
washed  out,  and  disinfected  with  formalin  and  iodine.  The  cervix 
uteri  is  brought  into  view  by  means  of  one  or  two  Simon  retractors, 
seized  with  strong  vulsellum  forceps,  and  drawn  toward  the  vulva. 
A  free  incision  with  scissors  is  made  all  around  the  cervix.  The  loose 
tissues  around  the  cervix  are  stripped  back  easily  by  means  of  the  finger 
or  handle  of  the  scalpel,  keeping  as  close  to  the  uterus  as  the  disease  will 
permit.  Small  bleeding  points  are  controlled  by  catgut  ligatures.  In 
this  way  the  surrounding  structures  may  be  stripped  back  from  the 
uterus  until  the  exposed  part  of  the  cervix  is  measured  by  a  zone  three- 
quarters  of  an  inch  or  more  wide.  This  zone  extends  anteriorly  and 
posteriorly  to  the  anterior  and  posterior  uteroperitoneal  reflexions, 
and  laterally  to  the  broad  ligaments.  The  uterus  can  now  be  drawn 
down  much  lower,  and,  with  the  bladder  thus  separated  from  the 
uterus,  the  ureters,  which  lie  close  to  the  uterus,  can  be  avoided 
easily.    The  post-cervical  structures  now  are  separated  further  by  means 


300      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

of  the  finger  or  the  handle  of  the  scalpel,  or  the  closed  blunt  scissors, 
until  the  cul-de-sac  of  Douglas  is  opened.  This  opening  is  enlarged 
easily  by  introducing  the  two  index-fingers  and  tearing  laterally  to  the 
region  of  the  broad  ligaments.  A  large  gauze  sponge,  with  a  string 
attached  to  facilitate  removal,  now  is  forced  through  into  the  cul-de- 
sac  of  Douglas.  This  will  protect  the  pelvic  viscera  and  absorb  blood 
during  the  remainder  of  the  operation. 

A  like  opening  anterior  to  the  uterus  between  the  uterus  and  bladder 
is  made  also  into  the  peritoneal  cavity;  this  opening  is  enlarged  to  the 
region  of  the  broad  ligaments  by  lateral  tearing  with  the  index-fingers, 
and  the  peritoneal  edge  of  each  opening,  if  the  operator  so  elect,  may 
be  stitched  to  the  vaginal  edge.  The  whip-stitch  by  which  this  is  done 
anteriorly  and  posteriorly  reduces  the  size  of  the  wound,  prevents 
bleeding,  and  thereby  simplifies  the  operation.  The  anterior  opening 
sometimes  may  be  made  more  easily  by  passing  the  index-finger  through 
the  posterior  opening,  and,  if  possible,  hooking  it  over  the  broad  liga- 
ment, so  that  it  may  serve  in  some  degree  as  a  guide,  and  thereby 
prevent  the  operator  from  wounding  the  bladder,  ureters,  or  anterior 
uterine  wall.  Then  the  index-finger  of  the  left  hand  or  a  blunt  hook 
over  the  left  broad  ligament,  the  ligament  is  drawn  down  and  transfixed, 
and  tied  en  masse,  or,  if  very  large,  in  sections.  The  application  of  the 
ligatures  may  be  facilitated  by  anteverting  the  uterus  and  drawing 
the  corpus  through  the  anterior  opening  by  means  of  vulsellum  forceps. 
This  twists  the  ligaments  upon  themselves,  makes  them  smaller,  and 
brings  their  upper  margins  within  reach.  Separate  ligatures  usually 
are  needed  for  the  uterine  appendages.  The  following  plates  will 
show  the  technique  of  the  operation.  The  ligatures — preferably  catgut 
—are  passed  by  means  of  aneurism-needles,  or  with  the  ordinary 
threaded  needle  and  forceps.  In  some  cases  an  entire  ligament  may 
be  secured  by  a  single  ligature,  but  more  frequently  portions  of  it  on 
either  side  are  tied  progressively  and  cut  away  from  the  uterus  until 
the  organ  finally  is  removed.  In  many  cases  hysterectomy  is  facili- 
tated by  dividing  the  uterus  into  halves.  Each  half  then  may  be 
drawn  through  the  vagina  separately  and  removed. 

Vaginal  Hysterectomy  with  Haemostasis  by  Forcipressure. — Hsemostasis 
by  forcipressure  is  the  same  in  general  technique  as  that  by  ligature 
except  the  use  of  forceps  in  place  of  the  ligature.  After  the  open- 
ings anterior  and  posterior  to  the  uterus  have  been  made  the  liga- 
ment is  drawn  down  and  seized  with  haemostatic  forceps,  the  grasp 
being  at  a  sufficient  distance  from  the  uterus  to  prevent  the  instruments 
from  slipping  off  after  the  organ  has  been  severed.  The  forceps  should 
be  heavy  and  with  jaws  about  tw^o  inches  long.  Various  broad  ligament 
clamps  have  been  devised,  but  none  fulfils  the  indication  better  than 
the  straight,  strong  haemostatic  forceps.  The  forceps  handles  are  locked 
securely,  the  ligament  is  severed  close  to  the  uterus,  and  the  whole 
uterus  pulled  outside.  The  organ  now  hangs  by  the  other  broad  liga- 
ment. This  in  turn  is  clamped  in  the  same  way,  and  the  uterus  is 
removed  by  a  few  strokes  of  the  scissors.    The  ovaries  and  Fallopian 


TREATMENT  OF  PELVIC  INFLAMMATION  301 

tubes,  unless  already  included  with  the  broad  ligaments,  may  be  secured 
by  separate  forceps.  It"  upon  examination  the  operator  fears  that  the 
broad  lijiament  is  diseased  beyond  the  grasp  of  tiie  first  forceps,  he  may 
j)nt  on  other  forceps  back  of  those  first  applied.  Tlie  first  forceps  may 
then  be  removetl  and  the  diseased  tissues  cut  a\va,>'.  Fatal  hemorrhage 
has  resulted  from  slipping  of  the  broad  ligament  forceps;  hence  the  neces- 
sity of  so  making  the  incision  through  the  ligament  as  to  leave  consid- 
erable tissue  on  the  distal  side  of  the  forcej^s.  To  prevent  the  forceps 
handles  from  sitappiitg  apart,  they  should  he  tied  together  securely  with 
strong  thread. 

In  many  cases  the  uterus  is  much  enlarged,  and  the  ligaments  there- 
fore on  either  side  extend  so  high  in  the  pelvis  that  they  cannot  be 
drawn  down  within  the  grasp  of  a  single  pair  of  forceps.  Then  one 
pair  of  forceps  may  be  put  on,  and  that  part  of  the  ligament  which  is 
in  their  grasp  divided.  The  uterus  can  then  be  drawn  farther  down, 
and  the  remaining  portion  of  the  ligament,  having  been  clamped  by 
one  or  more  forceps,  may  be  se\'ered.  If  so  much  space  in  the  vagina 
is  occupied  by  forceps  as  to  impede  the  operator,  a  single  forceps  may 
be  applied  back  of  two  or  more,  and  the  latter  then  removed.  Some 
operators  leave  the  vaginal  wound  open  for  drainage  with  or  without 
gauze  packing.  If  no  packing  is  used,  the  peritoneal  margins  of  the 
wound  usually  fall  together  and  promptly  unite.  Numerous  cases, 
however,  of  annoying  intestinal  adhesions,  protrusion  of  the  bow^el, 
fecal  fistula,  intestinal  obstruction,  and  peritonitis  prove  the  danger 
of  the  open  treatment.  The  wound  may  be  closed  by  the  continuous 
or  interrupted  catgut  suture,  or,  as  shown  in  Figure  142,  E,  by  small 
pressure-forceps.  If  drainage  is  required,  a  small  rope  of  twisted  gauze 
or  a  rubber  tube,  or  both,  may  be  inserted  between  the  sutures  precisely 
as  would  be  done  in  closing  any  other  wound.  The  vagina  then  is  packed 
lightly  with  gauze,  and  absorbent  dressing  is  secured  to  the  vulva  by 
a  T-bandage,  and  changed  sufficiently  often  to  keep  it  dry. 

Whenever  practicable  the  broad  ligament  stumps  should  be  drawn 
down  into  the  vagina  and  fixed  there  by  catgut  sutures,  so  that  every- 
thing included  in  the  bite  of  the  forceps  may  be  in  the  vagina.  The 
advantage  of  this  is  twofold:  1.  All  traumatisms,  except  the  simple 
peritoneal  wound,  are  excluded  from  the  peritoneum.  2.  The  liga- 
ments, when  united  to  the  upper  end  of  the  vagina,  support  the  pelvic 
floor,  and  with  it  the  rectum,  bladder,  and  vagina,  so  that  enterocele 
vaginalis  is  prevented.     See  Figures  136  to  142. 

Accidents  of  Vaginal  Hysterectomy. — Rectovaginal  and  vesicovaginal 
fistula?  are  among  the  accidents  of  vaginal  hysterectomy.  Should 
either  of  these  accidents  occur,  it  is  only  necessary  to  use  interrupted 
sutures  at  the  point  of  the  fistula  in  uniting  the  peritoneal  edges  to  the 
vaginal  edges  of  the  wound  in  addition  to  the  whip-stitch  already 
described.  These  sutures  should  not  be  buried,  but  should  include  the 
peritoneal  and  vaginal  margins  so  that  peritoneum  will  cover  the  fistula. 
The  strong  tendency  of  peritoneal  surfaces  to  adhere  to  any  exposed 
surface  renders  closure  of  the  fistula  bv  this  means  almost  certain. 


Explanation  of  Figure  136 

A.  Vaginal  hysterectomy.  The  patient  in  the  dorsal  position;  the  uterus  having 
been  curetted  and  its  cavity  disinfected. 

The  vagina  and  cervix  uteri  are  exposed  by  retractors  in  the  hands  of  assistants. 

The  OS  uteri  externum  has  been  closed  by  a  continuous  suture,  to  protect  the 
operation  wound  and  the  peritoneum  from  the  uterine  secretions. 

The  cervix  uteri  has  been  seized  by  strong  flat  vulsellum  forceps  in  the  left  hand 
of  the  operator  and  drawn  strongly  down  toward  the  vulva. 

The  operator,  with  scissors  in  his  right  hand,  is  making  a  free  incision  through  the 
mucosa  all  around  the  cervix  uteri  in  the  line  of  the  uterovaginal  attachment.  The 
black  and  white  dotted  lines  indicate  the  direction  of  the  incision. 

The  bleeding  points  are  secured  by  fine  catgut  ligatures — not  shown.  ' 

B.  The  mucosa  all  around  the  uterus  has  been  divided  by  scissors.  While  strong 
traction  is  being  made  on  the  uterus  by  the  forceps  in  the  right  hand  of  the  operator, 
the  left  index  finger  is  used  to  strip  back  the  circumuterine  tissue  all  around  the 
cervix.  The  stripping  process  is  continued  until  it  has  exposed  a  zone  of  raw  tissue 
an  inch  or  more  wide,  when  the  uteroperitoneal  reflexion  will 'be  recognized  by  the 
loose,  thin,  membranous  character  of  the  tissue,  and  by  the  fact  that  under  the  finger 
it  slips  over  the  adjacent  peritoneal  covering  of  the  uterus.  The  stripping  process  is 
much  facilitated  by  having  the  finger  covered  with  one  or  two  thicknesses  of  gauze. 


302 


KlOUKE    130 


Sen-iidiagramniatie. 


303 


Figure  137 


Semidiagranimiatie. 


304 


Explanation  of  Figure   137 

Vaginal  hj^sterectomy  follows  pre\aous  Figure. 

A.  The  circumuterine  structures  have  been  stripped  down  to  the  utero-peritoneal 
fold ;  the  operator  seizes  this  fold  posterior  to  the  uterus  with  a  haemostatic  forceps 
in  the  left  hand,  and  with  scissors  in  the  right  hand  cuts  through  into  the  cul-de-sac 
of  Douglas. 

B.  The  operator,  with  the  index  fingers  inserted  into  the  cul-de-sac  of  Douglas 
through  the  opening  shown  in  A,  is  tearing  bilaterally  to  the  region  of  the  broad 
Ugaments. 

A  similar  incision,  not  shown,  is  then  made  into  the  peh-ic  cavity  anterior  to  the 

uterus,  and  enlarged  by  lateral  tearing  to  the  region  of  the  broad  ligaments  in  the 

manner  described  above,  so  that  the  uterus  is  attached  to  its  surroundings  by  only 

the  broad  ligaments. 

335 


EXPLAXATION"    OF    FlGTTRE    138 

Vaginal  hysterectomy  follows  pre^aous  Figures. 

The  uterus  has  been  freed  from  its  surroundings  anteriorly  and  posteriorly  as 
described  in  Figures  136  and  137. 

A.  While  the  uterus  is  drawn  strongly  downward  and  to  one  side  -with  vulsellum 
forceps  in  the  hand  of  an  assistant,  the  operator  introduces  the  left  index  finger 
through  the  posterior  vaginal  opening  in  the  cul-de-sac  of  Douglas  and  brings  the 
finger-tip  out  into  the  vagina  through  the  anterior  opening,  so  as  to  hook  it  over  the 
left  broad  ligament ;  the  ligament  thus  held  on  the  finger  is  transfixed  at  two  points 
by  a  threaded  needle  passed  blunt  end  first,  so  that  the  ligature  shall  include  the 
entire  ligament  except  the  upper  and  lower  borders. 

B.  The  needle  has  been  drawn  through  the  broad  ligament,  lea\'ing  the  ligature  in 
place  ready  to  be  tied. 

C.  The  ligature  has  been  tied  tightly  and  is  being  secured  against  possible  slipping 
by  an  additional  stitch  on  the  proximal  side  of  it;  the  entire  ligature  when  tied  is 
shown  in  Figure  139.  Observe  that  the  ligature  does  not  compress  the  entire  liga- 
ment, but  leaves  out  a  margin  on  the  upper  and  lower  border,  so  that  collateral  circu- 
lation may  continue  to  supply  and  keep  alive  the  distal  portion  of  the  stump;  this 
prevents  gangrene  and  sloughing  of  the  stump,  and  is  therefore  a  very  essential  feature 
of  the  operation. 

D  shows  the  form  of  needle  in  general  use  for  ligature  of  the  broad  ligament.     The 
device  of  an  ordinary  needle  passed  by  a  needle-forceps,  blunt  end  first,  is  simpler, 
and  because  any  size,  curve,  or  form  of  needle  maj-  be  used  at  a  constantly  varying 
angle  to  the  forceps,  is  more  practical. 
306 


Figure  138 


Semidiagramn-iatie. 


307 


Figure  139 


Semidiagramn-iatie. 


308 


Explanation  of  Figure  139 

Vaginal  hysterectomy  follows  previous  Figures. 

A.  The  cervix  uteri  is  drawn  strongly  downward  and  to  one  side  by  vulsellum 
forceps  in  the  hand  of  an  assistant;  the  left  broad  ligament  having  been  ligatured  en 
masse  as  shown  in  Figure  138,  is  exposed  by  the  operator's  left  index-finger  and  is  cut 
from  the  uterus  about  one-half  inch  from  the  ligature  with  scissors  in  the  operator's 
right  hand. 

B.  The  uterus  having  been  freed  from  its  attachment  anteriorly,  posteriorlj',  and 
on  the  left,  is  drawn  outside,  and  the  corpus  is  seized  with  another  pair  of  forceps; 
these  forceps,  together  with  those  on  the  cer\dx,  are  placed  in  the  hand  of  an  assistant, 
who  makes  traction  on  them,  thus  pulling  the  uterus  strongly  downward  and  to  one 
side,  while  the  operator  ligatures  en  masse  and  severs  the  right  broad  ligament  in  a 
manner  precisely  similar  to  that  already  described  for  tj-ing  and  cutting  the  left; 
the  uterus  haA-ing  thus  been  removed,  the  vaginal  wound  will  be  closed  by  interrupted 
or  running  catgut  sutures,  as  shown  in  Figure  141.  These  sutures  may  secure  both 
the  peritoneal  and  vaginal  margins  of  the  wound  or  only  the  peritoneal  margins; 
in  either  case  thej^  should  so  include  the  ligatured  stumps  of  the  broad  ligaments  as 
to  fix  them  in  the  wound  where  they  may  give  normal  support  to  the  rectum,  vagina, 
and  bladder.  If  drainage  is  required,  the  wound  should  be  left  partially  or  wholly 
open  for  that  purpose.  The  central  third  of  the  wound,  if  not  sutured,  will  usually 
suffice  for  drainage.     The  gauze  drain  is  commonly  preferred. 

309 


Explanation  of  Figure  140 

Vaginal  hysterectomy  follows  pre^-ious  Figures. 

In  the  majority  of  cases  it  is  impracticable  to  include  the  entire  broad  ligament  in 
a  single  ligature,  and  it  is  necessary  therefore  to  tie  it  in  parts;  this  is  called  progressive 
ligature  of  the  broad  ligament. 

A  shows  the  broad  ligament  being  progressively  tied  from  the  lower  to  the  upper 
margin;  the  first  ligature  is  being  introduced  on  the  lower  margin.  As  each  ligature 
is  introduced,  the  ligatured  portion  is  cut  until  the  entire  ligament  is  severed  from  the 
uterus 

B.  In  some  cases  the  ligament  is  too  inaccessible  for  progressive  ligature  from  the 
lower  to  the  upper  margin;  then  the  corpus  uteri  may  be  delivered  through  the  anterior 
vaginal  wound  and  drawn  by  strong  forceps  to  the  vulva,  so  as  to  twist  the  ligament 
on  itself  and  thereby  reduce  the  size  of  it  and  render  it  accessible  for  progressive 
ligature  from  the  upper  to  the  lower  border;  the  beginning  of  such  a  ligature  is  here 
shown. 

C.  In  some  cases  the  ligaments  are  inaccessible  for  ligature  in  the  manner  described 
under  A  and  B.  The  uterus  may  then  be  seized  by  two  strong  forceps,  one  on  either 
side  of  the  cervix,  drawn  strongly  toward  the  vulva,  bisected  with  scissors  in  the 
median  line  of  the  longitudinal  axis,  and  each  half  drawn  outside;  the  ligaments 
may  then  be  ligatured  and  the  uterus  thus  removed  in  two  parts.  Bisection  of  the 
uterus  should  be  avoided  when  possible,  for  it  exposes  the  wound  to  infection  from 
the  endometrium. 

310 


Figure  140 


Seniidiagraniniatie. 


311 


Figure  141 


Semidiagramrt-iatie. 


312 


EXPL.WATIOV    OF    FiGCRE     141 

^'aginal  hystpreotoiny  follows  previous  Figures.  In  most  cases  the  ligatured  stumps 
of  the  broad  ligaments  can  be  drawn  down  into  the  vagina;  then  the  usual  method 
has  been  to  fasten  them  by  sutures  at  each  end  of  the  closed  vaginal  wound,  in  such 
a  way  that  the  ligatured  stumps  shall  be  in  the  vagina  below  the  level  of  the  vaginal 
wound.  The  ligatures  ordinarily  should  not  be  applied  en  rna.sne  around  the  entire 
ligament  in  such  a  way  that  the  ligatured  portion  will  slough.  It  is  better  if  possible 
to  apply  them  so  that  no  sloughing  can  occur;  that  is,  to  let  the  ligatures  include 
only  that  portion  of  the  ligament  through  which  the  arteries  i^ass.  This  plate  shows 
a  very  practical  method  of  treating  the  ligatured  ends  of  the  broad  ligaments  in  such 
a  manner  as  to  avoid  sloughing  of  the  ligatured  stumps  and  to  fix  them  in  the  vaginal 
wound.  The  method  here  illustrated  is  applicable  only  to  those  cases  in  which  the 
ligaments  are  sufficiently  long  to  permit  either  end-to-end  appro.ximation  or  the  fold- 
ing of  one  upon  the  other  and  the  fixation  of  them  in  the  vaginal  wound  between  the 
vaginal  and  peritoneal  sides  of  it. 

A.  The  ligatured  stumps  are  drawn  down  into  the  vagina  by  means  of  pressure- 
forceps.  The  anterior  peritoneal  margin  of  the  vaginal  wound  is  being  united  to  the 
posterior  margin  hy  a  continuous  catgut  suture.  At  both  ends  of  the  line  of  union 
this  continuous  suture  secures  the  broad  ligaments,  so  that  they  cannot  slip  back  into 
the  pehnc  ca\-ity.  Only  one  ligature  is  here  shown  on  each  broad  ligament.  In  the 
majority  of  cases  more  than  one  ligature  may  be  required. 

B.  The  anterior  and  posterior  peritoneal  margins  ha\-ing  been  united,  as  shown  in 
-■1,  the  broad  ligaments  are  brought  together  by  end-to-end  approximation  and  united 
by  a  continuous  catgut  suture.  The  united  ends  of  the  broad  ligaments  are  now  in 
contact  with,  and  in  front  of,  the  united  peritoneal  margins,  shown  in  ^.• 

C.  The  anterior  and  posterior  margins  of  the  peritoneal  wound  have  been  united, 
and  the  broad  ligaments  have  been  approximated- end-to-end  by  continuous  sutures, 
as  shown  in  A  and  B.  The  anterior  and  posterior  margins  of  the  vaginal  mucosa  are 
being  united  by  a  continuous  catgut  suture,  making  a  line  of  union  from  side  to  side. 
This  suture  completes  the  operation. 

D.  In  some  cases  the  broad  ligaments  are  so  long  that  instead  of  uniting  them 
ehd-to-end  they  may  be  folded  one  upon  the  other,  and  so  fastened  together.  The 
anterior  and  posterior  peritoneal  margins  have  been  united  in  precisely  the  same 
manner,  as  sho'wn  in  .-1. 

E.  The  anterior  and  posterior  peritoneal  margins  of  the  vaginal  wound  have  been 
united  bj^  transverse  lines  of  union,  as  shown  in  A  and  D.  The  ends  of  the  broad 
ligaments  have  been  folded  upon  themselves,  and  are  being  united  by  a  continuous 
catgut  suture  along  the  lower  borders  of  them.  A  similar  suture  is  to  be  introduced 
along  the  upper  borders.  The  ligaments  ha\-ing  thus  been  united,  are  to  be  covered 
by  union  of  the  upper  and  lower  margins  of  the  vaginal  mucosa,  as  shown  in  C. 

The  method  of  fixing  the  ends  of  the  broad  ligaments  between  the  peritoneal  and 
vaginal  sides  of  the  wound  ■will  be  found,  when  practicable,  to  have  great  value,  for 
the  ligaments  so  fixed  can  then  perform  the  important  function  of  holding  the  peh-ic 
viscera  high  up  in  the  peh-is  and  of  preventing  prolapse  of  the  peh-ic  floor  (rectum, 
vagina,  and  bladder),  a  not  uncommon  and  most  unfortunate  result  of  vaginal  hys- 
terectomy when  performed  by  the  older  methods. 

The  method  of  overlapping  the  ligaments  will  always  be  possible  in  the  operation 
of  vaginal  hysterectomy  when  performed  for  complete  procidentia  uteri,  and  is  strongly 
lu-ged  in  that  class  of  cases;  when  the  ligaments  are  not  sufficiently  long  for  end-to-end 
approximation,  they  may  be  fixed  in  the  vaginal  wound,  or  if  not  sufficiently  long 
for  this,  may  have  to  be  returned  to  the  pelvic  ca\-ity. 

Obser\'e  in  E  and  D  the  isolated  ligature  of  the  arteries.  This  form  of  ligature 
will  usually  be  quite  practicable,  except  for  ven,-  short  and  verj-  large  ligaments,  and 
when  practicable  should  always  be  employed,  because  it  insures  normal  circulation  in 
the  stumps  and  is  a  safeguard  against  sloughing.  It  should,  however,  be  rememhered 
that  in  hysterectomy  for  cancer  there  is  a  decided  advantage  in  removing  as  much  of  the 
ligament  as  possible;  hence,  the  ligature  en  masse  in  such  cases  may  be  preferable. 

313 


Fig  u  It  IS  142 


Sei-nidiagrammatie. 


314 


EXPLAXATION'    OF    FiGURE    142 

Vaginal  hysterectomy  follows  previous  Figures. 

Here  forceps  are  used  for  hsemostasis  instead  of  ligatures.  One  pair  of  forceps  has 
been  applied  to  the  right  broad  ligament  and  the  ligament  is  being  severed  bj-  means 
of  scissors.  The  second  pair  of  forceps  is  being  applied  previous  to  cutting  the  liga- 
ment entirely  away  from  the  uterus.  The  removal  of  the  uterus  is  accomplished  when 
the  same  procedure  has  been  repeated  on  the  other  broad  ligament.  Figure  /  shows 
full  size  of  the  jaw  of  the  pressure-forceps  here  used. 

B.  Hsemostasis  secured  by  one  pair  of  pressure-forceps  on  the  right  ligament  and 
two  pairs  on  the  left  ligament.  The  vaginal  wound  is  being  closed  by  continuous  cat- 
gut sutures.  The  peritoneal  layer  has  been  closed.  The  vaginal  laj-er  is  being  closed. 
Observe  that  the  suture  includes  not  only  the  margins  of  the  wound,  but  also  the 
ligament. 

C.  The  peritoneal  margins  of  the  wound  are  here  being  held  together  by  means  of 
small  haemostatic  forceps,  which  are  used  in  place  of  sutures.  The  method  of  closure 
with  forceps  is  indicated  when,  for  any  reason,  such,  for  example,  as  drainage,  the 
wound  should  not  be  closed  entirely,  or  when  the  low  condition  of  the  patient  does 
not  permit  the  operation  to  be  prolonged  by  suturing.  The  forceps  here  hold  the 
peritoneal  margins  together  and  sen-e  to  keep  intestines  and  other  abdominal  ^-iscera 
from  protruding  into  the  vagina.  "When  forceps  are  used  in  this  way  the  vaginal 
margins  of  the  wound  are  left  open,  and  the  vagina  is  packed  with  gauze.  All  forceps 
and  gauze  should  be  removed  •within  three  days,  and  after  the  removal  of  the  gauze 
the  vagina  should  be  gently  douched  twice  daily  with  a  low  pressure  0.25  per  cent, 
solution  of  lysol.     The  ^•^llva  should  be  dressed  antiseptically. 


315 


316      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

After-treatment  of  Vaginal  Hysterectomy. — The  general  procedure  in 
after-treatment  differs  in  nothing  from  that  of  ordinary  abdominal 
section.  The  forceps  and  vaginal  gauze  and  the  drain,  if  there  be  one, 
should  be  removed  at  the  end  of  about  forty-eight  hours,  and  a  0.5 
per  cent,  lysol  douche  given.  If  the  wound  has  been  left  open  and 
packed  with  gauze,  great  care  should  be  used  lest  in  the  removal  of 
the  gauze  a  loop  of  intestine  be  drawn  into  the  vagina.  The  douche 
may  be  repeated  daily,  or,  if  the  discharges  are  foetid,  oftener.  Let 
the  douche  be  a  weak  current,  lest  it  force  its  way  through  the  fresh 
adhesions  into  the  general  peritoneum. 

Relative  Merits  of  the  Ligature  and  Forceps  Operation. —  The  advantages 
of  ijressure-forceijs  over  the  ligature  are:  1.  The  greater  facility  of 
application  very  materially  shortens  the  operation;  therefore  in  a 
difficult  case,  with  inaccessible  broad  ligaments,  they  are  safer.  2. 
The  forceps  may  be  made  to  grasp  a  considerable  portion  of  the  broad 
ligament;  the  ligament  may  be  drawn  down  and  grasped  farther  back 
by  other  forceps;  more  of  the  ligament  may  in  this  way  be  included 
than  would  be  possible  with  the  ligature.  Whatever  the  forceps  grasp 
will  slough;  by  this  means  a  very  large  portion  of  the  ligament  may 
be  destroyed.  This  would  he  an  important  consideration  if  the  operation 
were  being  jjerforrned  for  malignant  disease,  because  some  part  of  the 
disease  which  the  ligature  might  have  missed  may  be  removed  with 
the  slough.  3.  The  forceps  facilitate  drainage.  The  secretions  find 
their  way  out  along  the  solid  instrument  by  continuity  of  surface. 
4.  If  the  forceps  are  constructed  and  applied  properly,  the  security 
against  secondary  hemorrhage  is  almost  absolute. 

The  disadvantages  of  the  forceps  as  compared  with  the  ligature  are: 
1.  They  cause  great  suffering  to  the  patient.  2.  Their  removal  is 
painful.    3.  Convalescence  is  apt  to  be  more  protracted  and  complicated. 

Both  the  ligature  and  the  forcipressure  operations  are  efficient  and 
satisfactory;  therefore,  whichever  is  most  convenient  or  will  most 
facilitate  the  operation  should  be  used.  The  forceps  will  often  be 
preferable  in  grave  cases,  especially  when  the  ligaments  are  very  thick 
and  inaccessible.    Both  methods  may  be  useful  in  the  same  case. 

Combined  Operation  of  Abdominal  and  Vaginal  Section. — When  the 
vulva  and  vagina  are  small  and  the  uterus  is  large,  high  in  the  pelvis, 
or  fixed,  removal  of  it  through  the  vagina  will  be  very  difficult.  Under 
these  conditions,  after  making  the  vaginal  incisions  and  separating 
the  cervix  from  its  surroundings,  as  already  described,  the  operation 
may  be  finished  better  through  an  abdominal  opening.  The  technique 
is  the  same  as  that  described  for  hysteromyomectomy. 

The  difficulties  of  vaginal  hysterectomy  are  much  increased  when 
the  uterus  and  its  appendages  are  fixed  by  adhesions.  The  uterus 
being  drawn  down  and  steadied  by  the  vulsellum  forceps  in  the  right 
hand,  the  adhesions  are  broken  up  by  the  finger  precisely  as  in  the 
operation  already  described  for  removal  of  the  appendages.  The 
adherent  appendages  having  been  freed,  the  operation  proceeds  as  if 
there  had  been  no  adhesions. 


TREATMENT  OF  PELVIC   I \ FLAMMATION  317 

Aspiration  of  Hydrosalpinx  through  the  Vagina.  The  coiitcnts  of 
sactusalpiiix  si-rosa^  liv<lr()salj)inx—  may  he  rcinoxcd  hy  aspiration,  and 
permanent  eure  possibly  may  result.  As  explained  in  the  Chapter  on 
Salpingitis,  ocelusion  of  the  ends  of  the  distended  tube  may  have  occurred 
meehanieally  from  swelling  of  the  mucosa  or  organically  from  adhesive 
inflammation.  Spontaneous  reopening  of  the  tube  and  restorati(jn  of  its 
functions  are  probable  under  the  former,  improbable  under  the  latter 
conditions. 

Technique    of    Aspiration. — The    diagnosis    of    sactosalpinx    serosa — 
hydrosalpinx — having  been  made,  the  aspiration  of  it  will  include  the 
following  steps: 
,    1.  ]Make  the  vulva  and  vagina,  so  far  as  possible,  aseptic. 

2.  Locate  the  sac  accurately  by  conjoined  examination. 

3.  Keeping  the  right  hand  behind  the  pubes  over  the  sac,  and  using 
the  left  index  and  middle  fingers  in  the  vagina  as  a  guide  to  the  point 
where  the  sac  bulges  most  toward  the  vaginal  fornix,  push  the  aspirator 
needle  into  the  sac  with  the  left  hand. 

4.  If  fluid  does  not  follow,  withdraw  the  needle  slightly  and  push 
it  in  again. 

5.  Having  removed  the  fluid,  the  action  of  the  aspirator  may  be 
reversed  and  the  sac  refilled  and  again  emptied  tw^o  or  three  times 
with  a  0.1  per  cent,  solution  of  formalin. 

6.  The  aspiration  and  washing  out  of  the  sac  having  been  com- 
pleted, place  a  pledget  of  wool  or  gauze  saturated  with  a  10  per  cent, 
solution  of  ichthyol  and  glycerin  against  the  cervix  uteri. 

The  fluid  having  been  removed,  it  should  be  subjected  to  a  bacterio- 
logical examination,  and  if  found  sterile  a  permanent  cure  may  be 
anticipated. 

Vaginal  Incision  and  Drainage. — Incision  and  drainage  is  a  recognized 
procedure : 

1.  In  the  treatment  of  chronic  sactosalpinx. 

2.  In  the  treatment  of  acute  pelvic  suppuration. 

3.  As  a  temporizing  measure  in  grave  cases. 

1.  Incision  and  Drainage  for  Chronic  Sactosalpinx. — Incision  and 
drainage  of  sactosalpinx  is  not  expected,  usually  even  when  successful, 
to  restore  the  function  of  the  tube,  but  rather  to  produce  instead  com- 
plete obliteration  of  the  lumen,  thereby  converting  the  tube  into  a 
cord.  The  same  process  sometimes  occurs  spontaneously  as  a  result  of 
recurring  appendicitis  or  recurring  salpingitis.  The  condition  is  then 
knowm  as  appendicitis  obliterans  or  salpingitis  obliterans,  a  result  which 
incision  and  drainage  may  bring  about  or  hasten. 

There  will  always  be  great  difficulty  in  drawing  the  line  between 
those  cases  which  may  be  relieved  by  the  operation  and  those  which 
demand  extirpation  of  the  diseased  organs.  The  former  treatment 
will  be  applicable  to  the  more  recent  and  acute  cases,  the  latter  to 
the  older  chronic  suppurative  cases  in  which  permanent  changes  have 
taken  place.  Notwithstanding  the  numerous  successful  cases  reported 
by  Vulliet,  Landau,  Goulliad,  Abbott,  and  others,  the  operation  is  not 
80 


318      INFECTIONS,   INFLAMMATIONS,   AND   ALLIED   DISORDERS 


strongly  indicated  in  very  chronic  pyosalpinx.  Success  requires  the 
removal  of  old  and  prevention  of  new  infection;  and  the  fulfilment 
of  this  requirement  in  the  many  possible  cavities  and  recesses  of  a 
pus-tube,  and  in  the  neighboring  pus-pockets  whose  walls  are  infected 
deeply,  is  often  beyond  the  power  of  simple  drainage  and  disinfection. 
This  operation,  which  had  been  nearly  obsolete  for  twenty  years, 
was  revived  after  the  development  of  aseptic  abdominal  surgery. 
Before  this  time  it  had  shown  relatively  few  immediate  cures  and  a 
discouraging  number  of  failures  to  cut  short  tubal  and  ovarian  sup- 
puration. On  the  other  hand,  the  more  radical  operation  of  extir- 
pating the  diseased  organs  has  saved  innumerable  women  from  life- 
long invalidism  or  death.  The  re-establishment  of  incision  and  drainage 
as  a  recognized  and  useful  procedure  has  been  made  possible  by  the 
introduction  of  sharp  uterine  curettage  and  asepsis.  The  operation 
should  include  the  thorough  removal  of  any  infection  in  the  uterus 
by  aseptic  sharp  curettage.  Failure  in  this  may  lead  to  disastrous 
results. 

Figure   143 


Tubercular  perimetritis  and  salpingitis;   sactosalpinx.     Uterus  and  appendages  removed   complete. 


When  the  distended  Fallopian  tube  can  be  isolated  by  palpation, 
incision  and  drainage  is  performed  as  follows:  First  the  vagina  and 
vulva  are  disinfected  thoroughly,  the  patient  being  in  the  lithotomy 
position;  the  sactosalpinx  by  steady  pressure  of  the  assistant's  hand 
is  now  fixed  downward  toward  the  vagina,  and  a  trocar  properly  curved 
or  straight,  guided  by  the  left  index-finger,  is  introduced  into  the  sac. 
On  this  trocar  as  a  guide,  sharp-pointed  scissors  are  used  to  enlarge  the 
opening  by  working  their  point  through  the  wall  with  alternate  spreading 
and  closing  of  the  blades  until  the  finger  can  be  introduced  into  this 
abscess  cavity.  It  is  essential  to  make  a  wide  opening  in  order  to  insure 
prolonged  and  free  drainage.  The  sac  is  to  be  washed  out  with  a 
1:  1000  solution  of  formalin. 

The  drainage  may  be  capillary  or  tubular  as  described  in  Chapter 
VII.  On  account  of  a  strong  tendency  for  the  vaginal  opening  to  close, 
it  may  be  necessary  every  few  days  to  insert  the  blades  of  a  long  heemo- 


TREATMENT  OF  PELVIC  INFLAMMATION  319 

static  forceps,  the  finger,  or  a  uterine  dilator  and  separate  them  by 
spreadin<::  the  iiandles.  After  the  first  \veei<  or  two  the  drains  may 
be  removed.  The  vagina  should  be  kept  clean  by  means  of  antiseptic 
douches.  The  prognosis  after  incision  and  drainage  is  better  lor 
hydrosalpinx  than  for  pyosalpinx  and  best  for  cellulitic  abscess. 
Persistence  of  suppuration  after  drainage  indicates  probable  tubal 
disease  and  may  require  removal  of  the  uterine  appendages. 

Tubercular  Suppurattun  otlers  great  resistance  to  all  conservative 
measures,  and  therefore  is  admittedly  an  indication  for  the  removal  of 
the  uterus  and  its  appendages;  indeed,  the  great  frequency  of  chronic 
tubercular  infection  materially  cuts  down  the  number  of  cases  suitable 
for  drainage.  It  is,  moreover,  usually  difficult  to  recognize  and  exclude 
the  tubercular  cases  until  the  diseased  tissue  has  been  removed  and 
examined.  The  suggestion  often  made  to  defer  radical  operation  until 
conservative  measures  have  been  tried  and  failed,  is  weakened  by  the 
fact  that  after  incision  and  drainage  removal  of  the  diseased  organs 
is  always  more  difficult,  tedious,  and  dangerous. 

2.  Incision  and  Drainage  for  Acute  Pelvic  Suppuration. — The  pelvic 
organs  and  products  of  inflammation  may  be  so  matted  and  fused 
together  in  a  conglomerate  mass  that  the  individual  organs  are  unrec- 
ognizable and  the  patient's  general  state  from  septic  infection  may 
be  so  grave  as  to  prohibit  a  radical  operation.  In  such  conditions, 
whether  the  suppuration  be  tubal,  ovarian,  or  parametric  (cellulitis) 
or  all  combined,  vaginal  incision  and  drainage  oft'er  the  following  advan- 
tages: 1.  llelative  freedom  from  mortality.  2.  Probable  preservation 
and  possible  restoration  to  function  of  the  diseased  organs. 

The  operation  begins  with  preliminary  sharp  curettage,  and  is  con- 
tinued as  follows:  The  incision  is  made  behind  the  uterus,  as  already 
described  in  this  chapter,  for  posterior  vaginal  section,  and  the  finger 
is  introduced  into  Douglas'  pouch,  which  generally  is  shut  off  from 
the  general  peritoneal  cavity  by  adhesions.  If  the  post-uterine  circular 
incision  gives  too  little  space  for  thorough  intrapelvic  exploration  and 
manipulation,  an  additional  perpendicular  incision  may  be  made  from 
the  centre  of  the  first  incision,  Figure  135,  in  the  median  line  of  the 
posterior  vaginal  wall  from  the  cervix  uteri  toward  the  rectum.  During 
the  making  of  the  second  incision  the  index-finger  of  the  left  hand 
should  be  in  the  rectum  as  a  guide  to  prevent  wounding  the  bowel. 
This  finger,  after  thorough  disinfection  and  change  of  rubber  glove, 
now  being  returned  to  the  pouch  of  Douglas,  and  the  right  hand  being 
over  the  abdomen,  the  examination  proceeds  as  in  the  ordinary  bimanual 
palpation.  The  examining  finger  penetrates  backward  and  to  either 
side  until  the  bimanual  sensation  indicates  that  the  free  peritoneum 
almost  is  reached.  In  shifting  the  finger  to  the  right  or  to  the  left, 
and  with  it  the  superimposed  hand,  the  septic  mass  usually  will  be  found 
and  punctured  by  the  finger,  without  difficulty. 

In  most  cases  the  infiltrated  material  will  be  evident  to  the  touch  of 
the  examining  finger  and  an  abscess-cavity  usually  will  be  found.  The 
accidental  opening  of  the  peritoneal  cavity  during  these  manipulations 


320      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

does  not  materially  increase  the  danger,  especially  if  the  pus  be 
sterile;  but  if  this  accident  occurs,  it  is  well  to  retain  the  finger  in 
the  opening  leading  to  the  abscess  until  any  escaping  pus  may  be  washed 
out  of  the  vagina  and  the  peritoneal  cavity  protected  by  gauze  packing 
against  the  inflowing  of  pus.  The  finger  should  then  be  withdrawn  and 
the  pus-cavity  evacuated.  Gentle  pressure  upon  the  abdominal  wall 
will  help  to  empty  the  abscess.  The  protective  packing  in  the  peritoneal 
cavity  is  replaced  now  by  fresh  gauze  and  the  finger  reintroduced  into 
the  pus-cavity.  This  is  for  the  purpose  of  finding  and  emptying  any 
adjacent  abscesses.     Both  sides  of  the  pelvis  having  been  thoroughly 

FiGDRE    144 


Incision  through  the  vagina  of  a  pelvic  abscess  with  sharp-pointed  scissors. 


explored  in  this  way  and  all  hard  inflammatory  masses,  whether  pus- 
containing  or  not,  having  been  penetrated  by  the  finger,  the  cavities 
thus  opened  should  be  packed  with  a  single  strip  of  sterilized  gauze 
about  three  inches  wide,  the  outer  end  of  which  should  be  retained 
carefully  in  the  vagina  to  facilitate  removal.  It  is  well  also  to  pass  into 
the  vaginal  wound  by  the  side  of  the  gauze  a  large  rubber  tube  in  order 
to  insure  efficient  drainage.  The  operation  is  completed  by  the  applica- 
tion of  a  light  vaginal  gauze  tampon  and  by  a  pad  over  the  vulva  which 
should  be  held  in  place  by  a  T-bandage.  No  instrument  excepting 
the  finger  should  be  used  after  the  preliminary  incision  through  the 
vaginal  wall  has  been  made. 

The  inflammatory  deposit  in  many  cases  will  be  found  in  the  median 


TREATMENT  OF  PELVIC  INFLAMMATION  321 

line  posterior  to  the  uterus;  in  other  cases  it  will  l)c  t'oiind  on  one  or 
hoth  sides.  In  such  cases  the  finj^er  cannot  he  worked  hack  in  the 
median  Hue  very  far  without  penetrating  the  abdominal  cavity,  but 
turning  it  to  either  side  it  may  usually  be  made  to  separate  the  layers 
of  the  broad  ligament,  and  without  invading  the  jx'ritoneum  at  all 
may  be  pushed  into  the  lateral  masses. 

;>.  Incision  and  Drainage  as  a  Temporizing  Measure.^ — In  acute  or 
chronic  peKic  sui)puration  when  the  condition  of  the  patient  is  so 
grave  as  to  prt)hibit  a  more  radical  operation  not  excluding  even 
tubercular  cases  which  generally  require  removal  of  the  uterus  and  its 
appendages  (pan-hy.s'iercctoDiy),  incision  and  <lrainage  is  indicated; 
and,  though  performed  as  a  temporizing  measure,  there  is  usually'  such 
prompt  and  pronounced  impro\-ement  as  to  permit  a  radical  operation 
later. 

Relative  Advantages  and  Disadvantages  of  the  Abdominal  and 
Vaginal  Routes  in  Pelvic  Surgery. — Advantages  of  the  Abdominal  Route. 
— 1.  There  is  a  larger  field  for  operation. 

2.  The  operator  may  see  what  he  is  doing,  instead  of  depending 
largely  on  the  sense  of  touch. 

.'5.  The  diagnosis  of  unsuspected  conditions  and  complications  is 
much  easier. 

4.  It  is  adapted  to  large  tumors  and  pus-sacs,  and  to  conditions 
high  in  the  pelvis. 

5.  The  appendages  may  be  removed  with  better  chance  of  avoiding 
rupture  of  a  pus-sac. 

6.  There  is  less  danger  of  wounding  intestine,  bladder,  or  ureter, 
and  greater  facility  in  the  control  of  hemorrhage. 

7.  Appendicitis  and  other  abdominal  lesions  so  often  complicating 
pelvic  disease,  difficult  to  reach  by  the  vagina,  are  easily  reached 
through  the  abdomen. 

8.  More  light  and  more  space  for  conservative  work. 
Advantages  Claimed  for  the  Vaginal  Route. — 1 .  It  gives  better  drainage, 

and  therefore  is  adapted  especially  to  complicating  vesical  or  intestinal 
fistula. 

2.  It  avoids  the  abdominal  scar  and  the  risk  of  ventral  hernia. 

3.  It  is  suitable  for  cases  of  small  tumors  without  high  adhesions. 

4.  When  properly  performed,  it  involves  less  danger  from  shock, 
and  therefore  is  suited  to  cases  of  extreme  pelvic  infiltration  and  ad- 
hesions for  which  the  abdominal  route  is  extrahazardous. 

5.  It  involves  less  handling  of  the  intestines,  and  therefore  less  con- 
sequent danger  of  shock  and  intestinal  adhesions. 

6.  Recovery  is  less  complicated  and  more  rapid. 

Choice  between  Abdominal  and  Vaginal  Routes. — Unfortunately,  the 
vaginal  route  is,  for  a  large  proportion  of  cases,  impracticable.  The 
long,  narrow  virgin  vagina  or  the  vagina  which  has  become  con- 
tracted from  senile  atrophy  may  render  the  field  of  operation  almost 
inaccessible.  A  very  large  uterus  with  exceptionally  short,  thick 
broad  ligaments  and  greatly  enlarged  appendages,  with  adhesions 
•21 


322      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

extending  beyond  the  reach  of  the  finger,  may  also  be  difficult  or  im- 
possible to  manipulate  through  the  vagina.  Under  such  conditions 
the  abdominal  route  is  much  safer. 

In  some  cases  it  is  well  to  begin  the  operation  in  the  vagina  and 
continue  by  that  route  as  far  as  the  greatest  safety  will  permit,  and 
then,  if  necessary,  open  the  abdomen  and  complete  the  operation  by 
the  combined  vaginal  and  abdominal  method.  Conversely,  abdominal 
section  may  have  to  be  supplemented  by  vaginal  section.  The  com- 
bined operation  may  be  the  deliberate  purpose  from  the  beginning,  or 
the  necessity  for  it  may  become  apparent  only  in  the  course  of  the 
operation. 

In  some  cases  the  advantages  of  the  two  routes  are  balanced  so 
evenly  that  either  is  permissible;  the  election  then  must  rest  with 
the  individual  bias  of  the  surgeon.  The  choice  of  procedure  has  in  a 
measure  been  forecast  in  the  description  of  special  operations  already 
set  forth. 

It  will  be  seen  from  the  above  that  each  method  has  its  special 
advantages  and  disadvantages.  Some  of  these  last  are  less  real  than 
they  seem;  for  example,  an  objection  to  vaginal  hysterectomy  is  that 
it  afi^ords  only  a  limited  field  of  operation  and  small  chance  for  visual 
control  of  the  work.  This  objection  does  not  necessarily  appeal  to 
the  skilled  operator.  The  danger  of  hemorrhage  is  avoidable  if  due 
precautions  are  used.  Injuries  of  the  bladder,  ureters,  and  intestine 
may  occur  with  either  method,  but  in  vaginal  hysterectomy  the  perfect 
drainage  makes  them  less  dangerous  if  they  do  occur. 

The  operator  should  not  permit  his  prejudice  in  favor  of  either 
route  to  lead  him  to  pursue  it  to  the  extreme,  for  that  part  of  an  opera- 
tion which  is  easy  by  the  vagina  is  often  most  difficult  by  the  abdomen, 
and  vice  versa. 

The  vaginal  route  was  for  a  time  much  in  vogue,  but  at  present, 
even  among  conservative  surgeons,  there  is  a  tendency  to  return  to 
the  abdominal  route. 

The  mortality  of  opening  into  the  yeritoneal  cavity  hy  either  route  in 
acute  suppuration  before  the  pus  has  had  time  to  become  sterile  is  excessive. 
The  withdrawal  of  such  cases  from  laparotomy  statistics  and  the  relegation 
of  them  to  the  statistics  of  vaginal  incision  and  drainage  would  reduce 
enormously  the  mortality  of  abdominal  surgery. 

Conservative  Operation  on  the  Fallopian  Tube.^ — Salpingo-stoma- 
tomie. — Resection  of  the  Fallopian  tubes,  called  salpingo-stomatomie, 
is  designed  in  selected  cases  to  save  and  restore  the  appendages  to  their 
normal  function,  instead  of  removing  them.  August  IMartin  reports 
65  cases  with  two  deaths,  neither  of  which  was  attributable  to  the 
operation.  In  1885  he  began  to  open  agglutinated  abdominal  ends  of 
tubes  and  to  study  microscopically  their  contents  and  the  condition 
of  their  walls.    His  method  is  as  follows: 

1.  Bring  the  tube  so  far  as  possible  up  into  the  abdominal  wound. 

1  A   Martin.     Die  Krankheiten  der  Eileiter,  p.  213. 


TREATMENT  OF  PELVIC  INFLAMMATION 


323 


2.  Protoft  tlu'  adjact'iit  i)rl\ic  organs  hy  si)()ii<;('  |)ackiiii;'  around 
the  tube. 

3.  Open  the  cmkI  ot"  till'  anipiilla  with  scissors.  The  |)()iiit  of  cli^iirc 
may  be  reeo^Mized  by  a  scar  in  which  the  fiinl)ria'  are  still  \isible. 

4.  Strip  tlie  tube  oi  fluid  by  pressure  applied  I'roni  tlie  uterine  toward 
the  abdominal  end. 

5.  If  the  contents  be  serous,  odorless,  and  all  fluid,  and  the  mucosa 
shows  only  slight  swelling  and  reddening  and  the  folds  arc  flattened 
only  by  pressure,  slit  tlie  tube  for  a  distance  of  about  one  inch. 

G.  If  the  condition  in  the  upper  ])art  of  the  tube  still  appears  to 
be  only  catarrhal,  close  the  longitudinal  wound  with  three  fine  catgut 
sutures.    Any  large  superfluous  tags  are  to  be  cut  off. 

7.  The  borders  of  the  tubal  mucosa  at  the  end  of  the  tube  and  the 
peritoneum  are  to  be  united  by  fine  catgut  sutures  so  that  tlie  opening 
shall  gape  and  the  mucosa  shall  stay  everted. 

Figure  145 


Retortion  of  the  tube.  The  distended  ampulla  to  the  right  closed  by  adhesive  inflammation.  The 
ampulla  of  the  tube  to  the  left  has  been  removed  and  the  mucosa  is  being  united  to  the  serosa  by  a 
continuous  suture;  the  longitudinal  slit  has  been  closed  by  a  continuous  suture. 


Hemorrhage  is  slight  and  easily  controlled  by  fine  ligatures.  The 
everting  sutures  at  the  end  of  the  ampulla  hold  the  new  ostium  close 
to  the  ovary.  The  now  reopened  tube,  together  with  the  ovary,  is 
replaced  in  the  abdomen.  Any  ovarian  adhesions  are  to  be  broken 
up.  According  to  INIartin,  this  operation  offers  no  greater  danger 
than  any  other  coeliotomy  complicated  by  peritonitis.  Pregnancy 
followed  in  tw^o  cases  in  which  this  operation  had  been  performed  on 
one  side  and  the  appendages  had  been  extirpated  on  the  other. 

The  general  conclusion  is  that  extirpation  for  atresia  of  tubes  whose 
contents  are  not  infectious  may  be  unjustifiable.  The  operation, 
how^ever,  can  result  in  restoration  of  function  only  when  the  uterine 
end  is  open,  or  when,  if  closed,  the  enclosure  is  due  to  swelling  and  not 
to  inflammatory  adhesion.  The  surgeon  should  not  venture  to  establish 
a  communication  between  an  occluded  Fallopian  tube  and  the  abdominal 


324      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

cavity  unless  a  smear  taken  from  the  secretion  at  the  time  of  the  operation 
gives  satisfactory  evidence  that  the  contents  of  the  tube  are  sterile.  Such 
evidence  necessarily  negative  is  always  subject  to  doubt. 

Figure  146 


Resection  of  the  ovary.  Conservative  operations  on  ovaries.  Partial  removal  of  right  ovary  by 
resection.  Xearly  all  of  left  ovary  preserved.  Small  detached  multiple  cyst  below  left  ovarj-  has 
been  removed  from  it.     The  ovaries  show  whip-stitches  for  closure  of  resection  wounds. 


Conservative  Operation  on  the  Ovary. — Resection  of  the  Ovary. — 
The  diseased  portion  of  an  ovary  may  be  removed  by  resection  and 
the  remaining  healthy  part  saved.  The  indications  for  resection  are 
these: 

1.  The  saving  of  a  portion  of  the  ovary  in  order  to  preserve  its 
reproductive  functions. 

2.  The  saving  of  a  portion  of  the  ovary  in  order  to  preserve  men- 
struation and  other  possible  important  functions  not  definitely  known, 
such  as  secretion  and  elimination. 

Reproduction  repeatedly  has  followed  the  operation  when  the  uterus, 
the  tube  or  a  portion  of  the  tube,  and  only  a  very  small  fragment  of 
the  ovary  were  left.  The  duty  of  the  surgeon  to  leave  for  this  purpose, 
when  practicable,  any  functioning  part  of  an  ovary,  is  therefore  clear. ^ 
The  preservation  of  menstruation  and  other  possible  functions  is  urged 
by  many  competent  observers.  As  a  rule,  women  are  better  off  mentally 
and  physically  if  menstruation  and  ovulation  are  maintained  up  to 
the  period  of  nature's  menopause.  The  possible  secretory  and  elimina- 
tive  functions  of  the  ovary  justify  the  operator  in  leaving  it,  or  any 

1  Polk.     "Operations  on  the  Uterine  Appendages,  with  a  View  to  Preserving  the  Functions  of  Ovula- 
tion and  Menstruation."  Transactions  of  the  American  Gynecological  Society,  1893. 


TREATMENT  OF  PELVIC  INFLAMMATION  325 

licalthy  jiortioii  of  it,  vww  though  the  (liseased  tubes  and  uterus  haw 
to  be  remoxed.' 

The  Opcnifion  of  Rc.srcfion  simply  iii\()lves  the  exeision  1).\  scalpel 
or  scissors  of  the  diseased  portion  and  closure  of  the  wound  by  means 
of  fine  interrupted  or  continuous  catfjut  sutures. 

All  conservative  operations  for  opening;  closed  tubes  and  resection 
of  o\aries  should  be  suj)plemente(l  by  the  release  of  the  appendages 
from  any  adhesions  wliich  may  be  present. 

'  G.  E.  Curatulo.     Secrezioiie  Interna  delle  Ovale.  1890. 


CHAPTER  XXI 

URETHRITIS— URETHRITIS  COMPLICATED  BY  PROLAPSE 

OF  THE  URETHRA— URETHRITIS  COMPLICATED  BY 

SUBURETHRAL  ABSCESS— CYSTITIS— PYELITIS 

URETHRITIS 

Etiology  of  Urethritis 

The  conditions  which  favor  and  excite  urethritis  are  the  same  as 
for  inflammation  in  general.  Although  urethritis  may  be  caused  by 
any  of  the  bacteria  found  in  pathological  conditions  of  the  female 
genito-urinary  tracts — such  as  the  bacillus  of  diphtheria,  streptococcus, 
staphylococcus,  and  the  bacillus  of  tuberculosis,  the  gonococcus  in  the 
vast  majority  of  cases  is  the  exciting  factor.  In  nearly  all  cases  the 
medium  of  infection,  which  occurs  either  directly  or  by  extension  from 
a  preceding  gonorrhoeal  vulvovaginitis,  is  coitus.  Indeed,  it  is  exceed- 
ingly rare  to  find  a  vulvovaginitis  of  gonorrhoeal  origin  which  has  not 
extended  to  the  urethra,  so  intimate  is  the  anatomical  relation  of  these 
parts.  Other  media  of  infection  are:  the  unclean  catheter,  sound, 
or  pessary,  masturbation,  and  coitus.  Am.ong  the  favoring  conditions 
are  the  passage  of  urinary  calculi  and  irritation  from  new  growths. 

Pathology  of  Urethritis 

The  mucosa  as  exposed  by  the  cystoscope— Chapter  III. — is  swollen 
and  red  from  distension  of  the  vessels  and  oedema,  and,  upon  instru- 
mental examination,  may  bleed.  The  inflamed  urethral  glands  stand 
out  prominently  as  oval  yellow  spots,  and  in  the  anterior  part  of  the 
urethra  sometimes  give  forth  a  secretion  which  looks  like  pus,  but 
may  be  only  epithelial  debris.  Gonorrhoeal  infection  in  the  acute  form 
is  intense  and  somewhat  characteristic.  The  swollen  mucosa,  at  first 
of  deep  red  color  and  finally  covered  with  pus,  protrudes  through  the 
meatus,  and  has  much  the  appearance  of  an  inflamed,  prolapsed  anus. 

Skene's  Glands. — The  urethral  glands  of  Skene,  as  described  by 
himself,  are  in  this  connection  of  great  pathological  significance.  They 
consist  of  two  glandular  tubules  situated  one  on  either  side  of  the 
urethrovaginal  wall.  Each  tubule  extends,  from  a  point  just  within 
the  meatus  urinarius,  parallel  to  the  urethra  to  a  distance  of  about 
five-eighths  of  an  inch.  The  tubules,  lined  with  columnar  epithelium, 
branch  into  the  muscularis  of  the  urethrovaginal  wall.  When  the 
urethra  is  swollen  and  the  meatus  everted,  the  openings  of  the  tubules 
(326) 


I'RETUh'ITIS  327 

appear  just  outsidr  t\\v  urethra.  The  iiorinally  j)hiee(l  ojjeiiiiifis  are 
seen  on  either  side  by  separating'  the  hihia  of  tiie  meatus  urinarius. 
When  intlanied,  tiiese  tubules  ^ave  forth  upon  pressure  a  wiiite  serous 
or  purulent  discharge.  The  mucous  membrane  around  their  ojx'uings, 
as  in  follicular  pharyngitis,  is  swollen,  thickened,  and  of  a  bright 
yellowish-gray  color,  or  the  orifices  may  be  surrounded  by  a  granular 
areola.  The  infection  involves  also  the  periglandular  structures. 
The  urethrovaginal  wall  in  the  neighl)orhood  of  the  tubules  usually 
is  swollen  and  everted.  The  inflammation  is  generally  purulent,  very 
often  gonorrhoeal,  and  may  give  rise  to  free  discharge.  Occlusicju  of 
the  tubules  by  adhesive  inflammation  and  the  consequent  formation 
of  retention-cysts  is  possible. 

Symptoms  and  Diagnosis  of  Urethritis 

The  symptoms  of  acute  urethritis  usually  are  so  interwoven  with 
those  of  the  associated  inflammations  that  it  is  not  always  practicable 
to  divide  them.  Pain  and  burning  upon  urination,  a  frequent  desire 
to  urinate  associated  with  almost  constant  bearing-down  pain  and  local 
tenderness,  which  is  especially  marked  in  the  gonorrhoeal  variety,  are 
the  most  constant  subjective  findings.  ^Yhen  these  symptoms  are 
associated  with  a  markedly  inflamed  urethra  which  bleeds  easily  upon 
manipulation,  the  diagnosis  of  urethritis  is  established.  The  bacterio- 
logical element  is  determined  by  smear  examination,  cultural  peculi- 
arities, by  the  complement  fixation  tests,  and  by  comparative  opsonic 
index  tests.  A  word  of  warning  may  be  permissible  at  this  point,  that 
all  Gram-negative  intercellular,  biscuit-shaped  diplococci  are  not  neces- 
sarily gonococci.  However,  for  all  practical  purposes,  the  clinical 
demonstration  of  a  copious  purulent  discharge  issuing  from  the  urethral 
meatus  is  nearly  pathognomonic,  especially  if  this  follows  in  from  two 
to  six  days  upon  a  suspicious  exposure. 

Chronic  urethritis  gives  rise  to  little  or  no  pain  on  urination.  Skene's 
glands  are  usually  the  focus  of  infection  in  the  chronic  form,  and  these 
are  very  frequently  mistaken  for  caruncle  of  the  urethra.  The  dift'er- 
ential  points  between  these  two  conditions  have  been  summed  up  in 
the  following  table: 


Inflammation  of  Skene's  glands 
1.   Urination  not  usually  painful 


Caruncle  of  the  Urethra 
1.   Urination  painful. 


2.  Two   protuberances    correspond    to    site    of  2.   Usually    only    one    protuberance    situated 

openings  of  tubules.  ;   anjTvhere   in   the    circumference   of   the    meatus 

or  within  the  meatus,   but  usually  on  the  pos- 
terior wall. 


3.   Removal  of  protuberances  does  not  cure. 


3.   Removal  cures. 


4.   Mouths  of  tubules  inflamed.  4.   Mouths  of  tubules  normal. 

The  gonococcus  may  become  intrenched  in  these  glands,  as  in  the 
glands  of  Bartholin,  and  from  time  to  time  furnish  infection  for  recur- 
rent  gonorrhoea.     Even   though  the  disease  may  have  disappeared 


328     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

from  the  external  surface,  reinfection  from  the  glands  ma;>'  occur 
repeatedly.  This  sources  of  reinfection,  unless  carefully  sought,  is 
liable  to   be  overlooked.     If  the  urethral  glands  are   in   a   state  of 


Figure   147 


Figure  148 


Figure   149 


Figure   150 


'"  -^-^ 

,•    *      "* 

''^ 

) 

^^^Hp 

A 

A  1 

1 

'^p 

^  • 

f 

^    -    -^_:  — 

1=1 

Figure  147. — Normal  meatus  urinarius.  The  openings  of  the  ducts  leading  from  Skene's  glands 
are  hidden  just  within  the  meatus  in  a  line  connecting  the  letters  A,  A.  The  black  and  white  dotted 
line  indicates  the  direction  of  an  incision  by  which  the  meatus  may  be  laid  open,  so  as  to  expose  the 
openings  of  the  ducts. 

Figure  148. — Meatus  laid  open  by  a  vertical  incision;  the  openings  of  the  ducts  leading  from 
Skene's  glands  exposed.   They  are  represented  by  black  dots  on  a  Hne  drawn  between  the  letters  A,  A. 

Figure  149. — Urethral  mucosa  dissected  out  and  laid  open  by  the  incision.  Two  fine  probes  are 
introduced  into  the  ducts  leading  from  Skene's  glands,  A,  A. 

Figure  150. — U.  cross-section  of  urethra;  A,  A,  cross-section  of  Skene's  ducts. 

suppuration,  the  pus  may  be  stripped  out  of  them  by  pressure  of  the 
finger  and  a  stroking  motion  against  the  urethrovaginal  wall.  Drops 
of  pus  are  shown  issuing  from  the  ducts  on  digital  pressure  in  Figure 
153.    Tubercular  infection  of  the  glands  has  been  observed  repeatedly. 


URETHRITIS 


329 


Treatment  of  Urethritis 

The  inildiT  non-iioiiorrlural  form,  it"  not  complicated  by  cystitis, 
may  usually  he  cured  promptly  by  a  few  applications  made  at  inter- 
vals of  four  or  five  days  of  a  .!  per  cent,  solution  of  silver  nitrate.  The 
application  is  made  by  an  applicator  wound  with  cotton,  throu{=:h  a 


FlClHK    151 


Figure  lol. — A.  A.  the  dvirts  leading  from  Skene's  glands  swollen  and  everted.  The  black  dots 
represent  the  opening:s. 

Figure  1.52. — Urethral  caruncle  at  one  side  of  the  meatus,  simulating  in  appearance  the  swollen 
and  everted  Skene's  duct.     Obser\-e  the  absence  of  the  opening  of  a  duct. 

Figure   153. — Expression  of  pus  from  the  ducts  of  Skene's  glands. 

Figure  1.54. — .\  large  h\T3odermic  syringe-needle  with  blunt  point  and  a  rubber  bulb  attached. 
This  is  intended  as  a  pipette,  by  means  of  which  may  be  injected  into  Skene's  ducts  medicinal  sub- 
stances for  treatment  of  infection. 


urethral  speculum.  Extreme  forcible  dilatation  of  the  urethra  has 
been  much  practised  for  the  relief  of  this  and  the  more  intense  forms 
of  urethritis,  and  often  has  given  prompt  and  pronounced  relief.  Per- 
manent injury  to  the  urethra  with  consequent  incurable  incontinence 
of   urine   has   resulted,  however,  about   three  times   in  a  hundred  of 


330      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

such  dilatations.  The  safe  limit  of  dilatation  is  not  over  fi^■e-eighths 
to  three-fourths  of  an  inch.  Emmet's  so-called  button-hole  operation, 
described  under  stricture  of  the  urethra,  answers  the  therapeutic 
indication  of  dilatation,  and  does  not  impair  the  retentive  power;  it 
also  has  the  advantage  of  rendering  the  diseased  mucosa  accessible  to 
direct  local  treatment.  The  opening  may  at  any  time  be  closed  by 
interrupted  sutures;  but  inasmuch  as  there  is  usually  no  functional 
impairment  this  repair  seldom  is  called  for. 

Figure   155 


Emmet's  button-hole  operation. 


Gonorrhoeal  urethritis,  if  acute,  is  treated  first  by  a  single  applica- 
tion of  a  10  per  cent,  solution  of  silver  nitrate,  then  by  rest;  compresses 
to  the  \ailva,  saturated  with  lead  water  and  laudanum,  or  sedative 
suppositories  in  the  rectum,  may  give  relief.  If  the  irritation  is  very 
great,  the  compress  may  be  saturated  with  a  5  per  cent,  solution  of 
cocaine  muriate.  The  medicinal  treatment  will  be  the  same  as  for 
gonorrhoea  in  the  male.     Urotropin  is  recommended  highly. 

Chronic  inflammation  in  Skene's  glands,  especially  if  gonorrhoeal, 
usually  resists  all  conservative  measures.  If  it  does  not  yield  to  the 
application  of  nitrate  of  silver  fused  on  a  fine  probe,  or  to  injections 
of  disinfectants,  the  entire  length  of  the  tubules  should  be  laid  open 
on  the  vaginal  side,  using  a  probe  as  a  guide.     The  glandular  struc- 


V  RET  1 1  inns  331 

tures  are  then  to  l)e  destroyed  by  caustic  or  by  excision  ■v\ith  scissors, 
and  the  surfaces  made  to  heal  by  jj^ranuhition.  To  fuse  the  silver  nitrate 
on  the  probe,  let  the  salt  be  melted  in  a  small  receptacle  over  a  spirit- 
lamp,  and  dip  the  end  of  the  probe  into  it  repeatedly  so  as  to  coat  it 
over  -with  a  thin  layer  of  the  salt. 

Treatment  of  Urethral  Stricture. — The  inflammatory  process  may 
ha\e  been  so  intense  as  to  produce  contractin<^  cicatricial  tissue  and 
consequent  stricture.  The  cause  of  this  uncommon  lesion  is  usually 
gonorrhcea  or  trauma.  The  treatment  is  dilatation  by  means  of  gradu- 
ated sounds,  as  in  stricture  of  the  male  urethra.  Should  dilatation 
fail,  a  urethrovaginal  fistula  may  be  made  and  the  vaginal  margins 
sutured  to  the  urethral  margins  of  the  opening.  AYhen  the  edges  have 
healed  securely,  the  fistula  may  be  closed  by  denudation  on  the  vaginal 
surface,  the  interrupted  silkworm  gut  sutures  being  so  placed  as  to  give 
ample  caliber  to  the  restored  urethra.    See  Figure  156. 

Complications  of  Urethritis 

Urethritis  Complicated  by  Prolapse  of  Urethral  Mucosa. — Prolapse 
of  the  urethral  mucosa  and  submucosa,  with  complicating  urethritis, 
has  been  described  by  Emmet.  The  prolapsed  mucosa  projects  from 
the  upper  or  lower  margin  of  the  meatus  or  surrounds  the  outliet  of  the 
urethra.  Ihe  urethra  is  obstructed,  and  as  the  obstruction  increases 
there  is  frequent  or  constant  urethral  tenesmus  and  difficult  urination. 
Finally,  the  entire  urethral  mucosa  and  submucosa  ma}'  be  rolled  out 
so  as  to  resemble  a  greatly  prolapsed  anus.  The  urethral  canal  dilates, 
and,  as  the  circulation  is  obstructed,  the  rolled-out  structures  become 
oedematous.  Cystitis  and  infection  of  the  kidney  are  possible  results 
of  the  partial  or  complete  retention  of  urine. 

When  the  prolapse  is  confined  to  the  region  of  the  meatus  urinarius 
and  the  rolled-out  tissues  are  from  the  outlet  of  the  canal,  they  resem- 
ble hemorrhoids,  and  may,  as  in  the  operation  for  hemorrhoids,  be 
removed  by  ligature. 

When  the  prolapse  is  extensive  and  circular,  removal  in  a  mass  is 
prohibited,  first,  because  more  prolapsed  tissue  usually  follows  and 
promptly  takes  the  place  of  that  which  has  been  removed;  second, 
because  a  distressing  stricture  of  the  urethra  may  result.  Prolapse 
of  the  urethra  may  be  the  result  of  the  traumatisms  of  labor  or  other 
causes  and  may  have  primarily  at  least  no  inflammatory  history. 

The  treatment  of  extensive  jyrolapse  from  any  cause  is  to  return  the 
displaced  mucosa,  if  possible;  and  if  relief  does  not  follow,  it  is  well 
to  make  a  small  vesicovaginal  fistula,  and  thereby  give  the  urethra 
perfect  rest.  If  this  measure  fails,  the  prolapse  may  be  cured  perma- 
nently by  making  what  Emmet  calls  a  button-hole  slit  in  the  urethro- 
vaginal wall  and  drawing  through  this  the  excessive  mucosa  and  cutting 
it  away.  The  sutures  for  closure  of  the  opening  are  introduced  before 
the  excision.  During  the  placing  of  the  sutures  a  sound  should  be  in 
the  urethra. 


332      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

Suburethral  Abscess  as  a  Complication  of  Urethritis  occurs  in  the 
urethrovaginal  wall.  It  has  been  described  by  Lawson  Tait  under 
the  name  urethral  cyst.  The  pathology  is  not  fully  explained.  In  the 
limited  number  of  cases  described,  the  sac  occupying  the  urethrovaginal 

Figure  156 


Emmet's  operation  for  prolapse  of  the  urethra. 


wall  varies  in  size  from  that  of  a  walnut  to  that  of  a  hen's  egg,  and  com- 
municates with  the  urethra  by  a  small  opening.  The  presence  of  this 
sac  has  been  explained  by  Tait  as  a  congenital  defect,  and  by  Kelly 
as  a  retention-cyst  formed  by  inflammation  and  occlusion  of  Skene's 
ducts  and  the  subsequent  perforation  of  the  urethral  wall.  Inasmuch 
as  Skene's  ducts  are  possibly  the  remnants  of  Gaertner's  ducts — rudi- 


cysrrns  3.33 

iiu'utiiry  \V()IfIi;iii  ducts^both  the  coii^iriiit;!!  and  ex  st  theories  iikin  he 
true. 

Tlie  tiinior  has  the  ai)i)earaiice  of  proiioiiiiceil  cystoeele,  is  well- 
defined,  and  \-ery  tender  to  tlie  toneh.  I'us  and  aniinoniaeal  urine  often 
eseape  from  it  tlirou|;h  the  urethra.  Tlie  tenderness  is  so  <i;reat  that 
amiesthesia  usually  is  required  for  examination.  If  the  communication 
with  the  urethra  is  exposed  by  a  urethral  speculum  and  pressure  be 
made  upon  the  sac,  one  may,  as  the  sac  is  reduced  in  size,  see  its 
contents  forced  into  the  urethra. 

TIk'  frcatiitcut  is  to  dissect  out  the  sac  lining-  from  the  urethro\a<;inal 
wall  and  close  the  wound  with  interrupted  silkworm-gut  or  catgut 
sutures.  Complete  anatomical  and  symptomatic  cure  follows  this 
operation.  If  the  sac  has  ruptured,  it  may  be  drained  l\v  gauze  packing 
held  in  place  by  a  T-bandage  until  it  heals  by  granulation. 


CYSTITIS 

In  pathology  and  symptoms,  inflammation  of  the  female  bladder 
differs  in  few  respects  from  that  of  the  male.  The  peculiar  sources 
of  infection,  the  relative  shortness  of  the  female  urethra,  and  the 
easy  access  to  the  bladder  through  the  vesicovaginal  wall,  however, 
give  to  the  etiology,  diagnosis,  and  treatment  a  clear  gynecological 
significance. 

Etiology  of  Cystitis 

Infection  may  occur  in  four  different  ways: 

1.  As  a  primary  focus  in  the  bladder. 

2.  By  the  descending  route  from  a  focus  in  the  kidney  or  ureter. 

3.  By  the  ascending  route  through  the  urethra. 

4.  Through  the  bladder  wall  by  continuity. 

Infection  by  all  of  these  routes  is  retarded  by  the  natural  protective 
agents  of  the  body,  and  especially  by  the  downward  current  of  the 
urine  which  freely  washes  the  urinary  tract,  and  which  being  acid  is 
hostile  to  the  culture  of  about  90  per  cent,  of  pathological  bacteria. 

In  addition  to  most  of  the  sources  of  infection  common  to  cystitis 
in  the  male,  the  female  bladder  is  more  subject  to  concurrent  infection 
from  the  same  causes  which  give  rise  to  infection  of  the  reproductive 
organs.  Susceptibility  is  increased  during  the  recurring  physiological 
congestion  of  menstruation,  and  especially  during  the  puerperal  state. 
Furthermore,  infection  may  spread  readily  from  the  reproductive  to  the 
urinary  organs. 

Predisposing  Causes. — All  wasting  diseases  such  as  tuberculosis, 
syphilis,  etc.,  together  with  all  conditions  of  perverted  metabolism, 
such  as  gout  and  diabetes,  and  all  acute  infections,  scarlet  fever,  typhoid, 
pneumonia,  etc.,  predispose  to  cystitis  by  lowering  the  general  body 
resistance.     Conditions  which  tend  to  alkalinize  the  normally  acid 

21 


'334     INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

bactericidal  urine  doubtless  predispose  to  the  multiplication  of  many 
forms  of  bacteria  within  the  bladder.  Other  conditions  also  in  which 
pathological  urine  is  secreted  by  the  kidneys  and  conditions  giving  rise 
to  h^ematuria  in  the  urinary  tract  also  predispose  to  cystitis. 

Exciting  Causes. — Except  in  the  comparatively  rare  cases  in  which  an 
irritative  inflammation  has  been  set  up  by  direct  contact  to  the  bladder 
mucosa  by  a  corrosive  or  by  a  hyperacid  urine,  cystitis  is  in  all  cases  the 
result  of  bacterial  invasion.    The  bacteria  most  frequently  found  are: 

1.  Bacillus  coli  communis. 

2.  Gonococcus. 

3.  Bacillus  tuberculosis. 

The  bacteria  less  frequently  found  are: 

1.  Proteus  vulgaris,  Hauseri. 

2.  Staphylococci  pyogenes. 

3.  Streptococci  pyogenes. 

4.  Typhoid  bacillus. 

It  is  agreed  generally  that  the  gonococcus  and  bacillus  tuberculosis 
are  prone  to  attack  the  healthy  bladder,  and  that  they  require  little  if 
any  predisposing  causes.  On  the  other  hand,  a  normal  bladder  is  said 
to  offer  much  resistance  to  the  other  bacteria — that  is,  they  do  not 
become  active  except  in  conjunction  with  definite  predisposing  causes. 

Ammoniacal  urine  is  known  to  result  from  the  decomposing  action 
upon  urea  of  certain  bacteria,  notably  the  proteus  vulgaris.  The  fre- 
quent association  of  alkaline  ammoniacal  urine  with  cystitis  has  given 
rise  to  the  more  or  less  common  and  wrong  impression  that  the  dis- 
ease depends  upon  the  irritating  action  of  urine  which  has  undergone 
ammoniacal  decomposition,  and  that  such  decomposition  is  associated 
necessarily  with  cystitis.  Johannes  Miller,^  of  Wurtzburg,  was  the 
first  to  overthrow  this  idea.  He  show^ed  that  in  73  per  cent,  of  the 
cases  of  cystitis  the  urine  was  acid.  Soon  after  the  observations  of 
Miller,  Melchior^  reported  the  results  of  sixty-two  very  accurate 
observations.  He  found  that  ammoniacal  decomposition  was  only  a* 
minor  phenomenon,  and  that  in  many  of  the  severest  forms  of  cystitis 
acid  urine  was  present  even  to  the  time  of  death.  Almost  all  investi- 
gators now  reach  the  uniform  result  that  the  bacillus  coli  communis, 
or  a  microbe  very  closely  related,  is  the  one  most  frequently  found  in 
cystitis.  Out  of  one  hundred  and  twenty  cases  collected  by  Rostoski 
this  germ  was  found  in  eighty.  Whenever  the  bacterium  coli  com- 
munis w^as  found  alone  the  urine  was  acid;  whenever  the  proteus 
vulgaris  was  found  it  was  alkaline.  Alkalinity  with  bacteria  coli 
communis  is  said  to  be  always  due  to  association  of  other  microbes. 

Pathology  of  Cystitis 

The  pathological  picture  of  cystitis  is  dependent  not  only  upon 
the  acuteness  or  chronicity  of  the  process  but  also  and  more  particularly 

1  Rostoski.     Deutsche  medicinische  Wochenschrift,  1898,  S.  235. 

2  Monatsbericht  iiber  den  Gesamtlei-stungen,  Heft  10. 


CYSTITIS  335 

upon  the  variety  of  bacteria  causing  the  condition.  In  general  the 
bacteria  which  give  rise  to  cystitis  are:  staphyhjcocci  aureus  and  albus, 
streptococcus,  gonococcus,  bacillus  coh  communis,  and  typhoid  bacillus. 
E.\cei)ting  the  (jonucocciin,  which  shows  a  special  predisposition  for  the 
trigone,  the  entire  inner  surface  of  the  bladder  usually  is  more  or  less 
affected. 

///  the  acute  stiuje  the  nnicosa  is  considerably  swollen  from  (edematous 
infiltration,  and  in  extreme  cases  may  be  lifted  from  the  underlying 
muscularis  and  may  present  a  corrugated  appearance.  Large  areas 
may  become  detached  and  may  leave  an  irregular  darker  colored  area 
of  muscularis  exposed. 

The  cystoftcope  shows  an  irregular  picture  of  congestion,  the  more 
acute  the  process  and  the  deeper  tiie  infection  of  the  mucosa,  the  less 
sharply  defined  are  the  congested  vessels  until  the  entire  surface  finally 
presents  a  uniform  deep  red  color. 

There  is  cloudy  swelling,  degeneration  of  the  epithelial  cells  of  the 
mucosa,  which  are  irregularly  arranged  and  forced  apart  by  interstitial 
infiltration.  The  capillaries  of  the  mucous  and  of  the  muscular  layers 
are  engorged;  red  and  white  blood  corpuscles  fill  the  interstitial  spaces, 
and  the  fibers  of  the  muscular  layer  are  separated  by  the  infiltration 
process. 

In  the  chronic  stage  the  pathology  of  the  bladder-wall  varies  with  the 
chronicity  and  virulence  of  the  inflammatory  process.  The  acute 
congestive  state  above  described  has  partially  or  wholly  subsided,  and 
is  replaced  by  one  or  more  secondary  degenerative  changes. 

These  changes  according  to. the  special  structures  involved  and  the 
nature  of  the  process  sometimes  have  been  designated  as  pericystitis, 
paracystitis,  interstitial  cystitis,  and  endocystitis.  The  difficulty,  not  to 
say  frequent  impossibility,  of  separating  these  varieties  one  from  the 
other,  and  the  fact  that  two  or  more  usually  coexist,  render  this  classi- 
fication, although  diagrammatically  attracti\'e,  clinically  impossible. 
The  above  terms,  however,  have  descriptive  value.  There  are  no  sharp 
lines  of  demarcation  between  these  anatomical  forms  to  designate 
the  various  forms  and  phases  of  infective  processes.  For  example, 
we  should  use  the  word  endocystitis  to  describe  not  a  distinct  lesion 
independent  of  the  rest  of  the  bladder,  but  rather  an  essential  part 
of  an  inflammatory  process. 

Certain  so-called  clinical  and  pathological  forms  and  phases  of  cystitis 
may  be  designated  as  follows: 

1.  Superficial  cystitis — catarrhal. 

2.  Suppurative  cystitis. 

3.  Ulcerative  cystitis. 

4.  Exudative  cystitis. 

5.  Exfoliative  cystitis. 

6.  Fissure  cystitis. 

7.  Foreign-body  cystitis. 

8.  Leucoplakia  cystitis. 

9.  Tubercular  cvstitis. 


336      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

1.  Superficial  Cystitis. — A  large  proportion  of  the  cases  of  chronic 
inflammation  are  of  this  variety.  Generally  it  is  called  catarrhal 
cystitis;  the  term  should  be  restricted  to  superficial  infection  and  to 
cases  in  which  the  product  of  inflammation  comes  from  the  superficial 
epithelial  elements  of  the  bladder  mucosa.  The  disease  is  marked  by 
some  swelling,  redness,  and  exfoliation  of  epithelial  cells;  the  urine 
contains  a  moderate  amount  of  pus  and  is  usually  acid.  Erosions, 
ulcerations,  and,  as  a  consequence,  more  abundant  suppuration,  may 
follow — that  is,  cystitis,  originally  catarrhal,  may  become  distinctly 
suppurative.  Great  alkalinity  of  the  urine  indicates  a  rather  advanced 
stage,  when  the  cystoscope  w^ill  reveal  a  deposit  of  grayish-white  color 
containing  mucus. 

2.  Suppurative  Cystitis. — In  this  form  the  inflammation  may  have 
been  diffuse  from  the  beginning  and  have  involved  both  the  superficial 
and  deeper  structures  of  the  bladder-wall.  As  well  stated  by  Senn, 
the  microbic  infection  is  of  sufficient  intensity  to  destroy  the  proto- 
plasm of  the  pathological  products  of  the  inflammation  and  thus 
transform  the  leucocytes  and  epithelial  and  connective-tissue  cells  into 
pus-corpuscles.  The  urine  contains  an  abundance  of  epithelial  cells 
and  pus.  Ulcerative  processes  may  involve  the  deeper  structures, 
and  in  exceptional  cases  may  lead  to  perforation.  The  urine  is  acid, 
or,  if  ammoniacal,  may  be  so  from  decomposition  due  to  the  intercur- 
rence  of  microbes  other  than  those  which  produced  the  original  infec- 
tion. The  proteus  vulgaris  will  often  be  found  in  ammoniacal  urine. 
Suppurative  cystitis,  both  in  its  acute  and  chronic  stages,  is  prone  to 
invade  the  ureters  and  kidneys.  In  fact,  chronic  uncomplicated  sup- 
purative cystitis  is  rare.  The  cystoscope  reveals  the  local  conditions 
as  already  described. 

3.  Ulcerative  Cystitis. — The  ulcerative  phase  of  cystitis  has  been 
mentioned  as  a  later  stage  of  catarrhal  or  suppurative  varieties.  The 
term  is  used  here  to  designate  that  variety  in  which  ulceration  is  the 
initial  or,  at  least,  a  very  early  factor.  The  infection,  as  described 
by  Senn,  appears  to  be  of  a  peculiar  kind  and  limited  in  extent.  The 
resulting  inflammation  leads  quickly  to  circumscribed  necrosis.  There 
is  at  first  a  single  circumscribed  ulcer,  the  so-called  "simple"  ulcer 
of  the  bladder  resembling  gastric  ulcer  and  the  round  duodenal  ulcer, 
which  gives  rise  to  an  increased  desire  to  urinate  and  to  an  intermittent 
hsematuria.  The  ulcer  may  become  incrusted  with  phosphates.  Frag- 
ments of  the  deposit  break  off  now  and  then,  and  may  be  passed  with 
painful  paroxysms,  or  may  be  retained  to  serve  as  nuclei  for  calculus 
formation.  Finally  the  bladder  becomes  contracted  and  the  mucous 
membrane  extensively  ulcerated.  Ureteral  and  renal  lesions  may  now 
arise.  Ulcerative  cystitis,  like  gastric  and  duodenal  ulcer,  is  found 
quite  frequently  in  young  men,  less  frequently  in  women. ^ 

4.  Exudative  Cystitis. — This  is  characterized  by  the  formation  upon 
the  bladder  mucosa  of  a  so-called  membrane;  hence  it  usually  is 
designated  by  the  rather  confusing  descriptive  terms,  "membranous," 

1  Adaptation  from  Senn. 


Figure   1. 


PLATE    X 

Cystitis  originating  in  the  Trigone  and  extending  to 
Adjacent  Surfaces.      Magnified. 


Figure  2.      Normal  Bladder  Mucosa.      Slightly  magnified. 


PLATE    XI 

Fic)iire    1.       Liiie;ir    Ulcer   of    Blndcler   Mucosa.       Matinifiecl. 


Figure  2.       Ulcerated   Patches   in   the  Trigone.      SHghtly   Magnified. 


CYSTITIS  337 

"diphtheritic,"  "croupous,"  or  "fibrinous."  The  exudative  mem- 
brane is  the  product  of  the  inflammation;  it  is  in  fact  apt  to  be  the 
pro(hict  of  extensive  necrotic  chanj^ies,  and  as  such  indicates  a  ^rave 
lesion.  There  may  be  extensive  destruction  even  in  the  muscuhiture 
and  especially  in  the  deep  blood-vessels  and  lymphatics.  The  urine 
usually  is  alkaline.  The  disease  has  been  observed  chiefly  in  puerperal 
women.  The  urine  contains  fibrinous  shreds  or  cast-off  j)atches  of 
membrane.  Cystoscopic  examination  rc\'eals  a  yellowish-wliite  mem- 
branous formation  which  often  may  be  picked  oft'  by  means  of  forceps 
passed  through  the  cylindrical  cystoscopy 

5.  Exfoliative  Cystitis. — This  variety  is  analogous  to  so-called  dis- 
secting metritis  and  dissecting  vaginitis.  The  infective  process  and 
inflammatory  reactions  are  most  virulent  and  intense,  and  result  in  the 
destruction  and  detachment  of  the  mucosa,  and  together  with  it  some- 
times of  the  muscular  layer  of  the  bladder;  these  may  be  expelled  in 
fragments  with  the  urine  or  may  have  to  be  removed  from  the  bladder 
by  a  surgical  procedure.  It  is  the  most  grave  and  \'irulent  form  of 
cystitis,  and  is  apt  to  be  fatal.  Macroscopical  and  microscopical 
masses  may  be  removed  or  thrown  off  from  the  bladder.  The  disease 
was  described  early  and  fully  by  Boldt.^ 

Exfoliative  cystitis  is  associated  usually  with  one  or  more  of  the 
following  mechanical  conditions:  1.  Retroversion  of  the  gravid  uterus 
in  50  per  cent,  of  cases.  2.  Protracted  birth  in  25  to  30  per  cent,  of 
cases.  3.  Incarcerated  pelvic  tumors.  4.  Retention  of  urine,  especially 
in  puerperal  cases,  common. 

Detached  membrane  in  the  bladder  may  cause  vesical  tenesmus,  or 
may  be  expelled  with  pain  and  straining,  or  may  be  passed  with  the 
urine  giving  rise  to  obstruction  in  the  urethra  and  consequent  retention. 
Death  may  occur  from  sepsis,  ursemia,  pyelitis,  or  peritonitis. 

6.  Fissure  Cystitis. — Fissure  cystitis  is  caused  by  infection  through 
a  traumatism  at  the  neck  of  the  bladder  or  in  the  trigone.  As  seen 
through  the  cystoscope,  the  fissure  is  covered  usually  by  a  brownish 
or  yellowish  exudate  surrounded  by  an  oedematous  area. 

7.  Foreign-body  Cystitis. — Cystitis  caused  by  foreign  bodies  (Figures 
157  and  15S)  varies  with  the  character  of  the  body  and  the  condi- 
tions of  infection.  A  smooth  body  may  be  tolerated  without  subjective 
symptoms.  A  rough  or  angular  substance  may  produce  trauma  and 
thus  open  the  way  to  any  form  of  infection.  The  foreign  body  is  the 
exciting  cause  and  opens  the  way  for  the  action  of  infecting  bacteria. 

8.  Leucoplakia  Cystitis. — This  affection  is  characterized  by  the  ap- 
pearance of  grayish  small  circumscribed  areas  situated  usually  in  the 
trigone.  The  epithelium  has  undergone  changes  which  render  it 
opaque  and  which  have  been  likened  to  the  changes  of  keratitis.  The 
cystoscope  reveals  a  number  of  grayish-white  reflecting  spots  of  a  diam- 
eter approximating  one-fourth  inch.  These  spots  while  desquamating 
are  below  the  level  of  the  surrounding  mucosa;  after  desquamation  has 

'  American  Journal  of  Obstetrics,  June,  1889. 


338      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 


ceased  they  become  flush  with  the  mucosa.  A  most  pronounced  sub- 
jective symptom  is  an  intolerable  and  almost  constant  desire  to  urinate. 
Micturition  may  be  attempted  as  often  as  once  in  fifteen  minutes 
through  the  day,  and  almost  as  frequently  during  the  night.  Leuco- 
plakia  results  from  long-continued  chronic  areas  of  inflammation;  it 
may  be  the  starting-point  of  general  cystitis. 

Figure  157 


Stone  in  the  liladiicr,  :i  cause  of  foreign-body  oystitis. 
Figure   158 


Hairpin  in  tiie  bladder, 


iuse  of  foreign-body  cystitis. 


Diagnosis  of  Cystitis 

When  the  diagnosis  of  cystitis  was  based  upon  the  presence  of  j^us 
in  the  urine  and  painful  and  frequent  urination,  which  usually  are  present, 
treatment  gave  less  satisfaction  to  the  physician  and  less  relief  to  the 
patient  than  that  of  almost  any  other  inflammatory  disorder.     Now 


CYSTITIS  339 

these  symptoms  are  recognized  as  results  not  only  of  inflaninuition 
of  the  bladder,  but  also  of  a  variety  of  other  lesions,  so  that  cystitis 
is  considered  properly  in  its  relation  to  certain  deeper  lesions  which 
individually  or  collectively  may  underlie  and  peri)etuate  it  or  may  result 
from  it.  Within  a  single  decade  the  management  of  this  disorder  has 
risen  from  the  plane  of  empiricism  and  has  taken  its  place  upon  the 
scientific  basis  of  patiiology.  This  change  has  come  about  chiefly  as 
the  result  of  etiological  investigations,  especially  including  bacterial 
causes,  and  of  improved  instrumentation  in  diagnosis  and  treatment. 
Indeed,  within  a  few  years  the  cystoscope  has  rexolutionized  our 
knowledge  of  the  pathology,  diagnosis,  and  treatment,  not  only  of 
cystitis,  but  of  many  other  hitherto  more  obscure  urinary  disorders. 

The  introduction  of  the  .r-ray  used  both  in  conjunction  with  the  cysto- 
scope and  ureteral  catheter  in  diagnosing  conditions  of  the  urinary 
tract,  above  the  bladder,  and  used  separately  especially  in  demonstrat- 
ing vesical  stones,  has  done  much  to  clarify  our  knowledge  of  cystitis. 

Cystitis,  in  the  first  place,  must  be  distinguished  from  simple  irri- 
tability of  the  bladder;  a  condition  found  in  neurasthenic  subjects, 
and  due  to  some  underlying  neurosis. 

In  the  beginning  of  cystitis  the  cystoscope  shows  the  blood-vessels 
to  be  defined  less  sharply  than  in  health.  Soon  the  normal  light  pink, 
almost  whitish,  color  of  the  mucosa  assumes  a  deeper  and  deeper  hue 
until  the  sharp  demarcation  between  the  vessels  is  lost  and  the  whole 
surface  is  finally  of  a  uniform  deep  red.  The  epithelium  may  be  ca'st 
off  in  particles  from  circumscribed  areas  either  narrow  or  broad,  and 
the  surface  thus  exposed  may  take  on  a  granular  appearance.  Finally, 
in  severe  cases  one  may  observe  pus  coagulation  and  excessive  swelling 
and  oedema  of  the  bladder-wall.  The  urine  in  such  cases  contains 
epithelial  detritus  and  pus-cells  in  -large  quantities. 

]\Iixed  infection  and  other  complications  may  render  it  difficult 
to  distinguish  beween  the  different  bacterial  varieties;  it  is,  however, 
often  desirable  to  differentiate  the  tubercular  from  other  varieties. 

Differentiation  of  Tubercular  from  Gonorrhceal  Cystitis 

Tubercular  cystitis  Gonorrheal  cystitis 


1.  Located  chiefly  about  the  trigone. 

2.  Inflammatory  reaction  zone  absent  or  not 
well-defined. 


1.  Not  at  all  so  confined. 

2.  Clear    inflammatory    reaction    zone,    later 
changing  to  dull  brown  color. 


3.  Tubercular  cystitis  not  common.  ]        3.   Common. 

4.  Characterized  by  presence  of  small  tubercles   i        4.  Characterized  early  by  insular  areas  of  re- 
situated  about  the  trigone  and  ureteral  orifices.        '   active    inflammation,    with    healthy    or    nearly 

healthy  intermediate  mucosa.  Later  insular 
areas  may  become  confluent  and  extend  over 
the  whole  mucosa. 


5.   No  projecting  tufts  of  pus. 


6.   No  subperitoneal  extravasation  of  blood. 


5.  Projecting  tufts  of  gonorrhceal  pus  are  apt 
to  be  present.  In  .chronic  stage  regions  of 
elevation  may  be  excavated  by  ulceration. 

6.  In  very  acute  stage  there  is  subperitoneal 
extravasation  of  blood. 


7.  Bacillus  tuberculosis.  I        "■   Gonococcus. 

.S.   Often  extension  from  kidney  and  from  gen-  8.  Extension  from  vagina,  vulva,  or  urethra. 

eral  tuberculosis. 

9.   Historj-  of  tuberculosis.    Great  pain;  hsema-  9.   History  of  gonorrhoea.     Less  pain;  seldom 

turia.  I   blood  in  urine. 


340      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

Tubercular  Cystitis  shows  further: 

1.  At  first  small  grayish  tubercles  or  nodules;  later  larger  nodules 
and  deep  ragged  ulcers. 

2.  Trigone,  base,  and  posterior  wall  of  the  bladder  most  affected; 
disease  may  extend  over  the  entire  bladder. 

3.  Bladder-wall  thickened  and  contracted. 

4.  Disease  may  end  fatally  in  a  few  months  or  may  continue  for 
years. 

In  the  Diagnosis  of  Tubercular  Cystitis  one  should  have  to  mind  the 
following  points: 

1.  Non-gonorrhoeal  cystitis  in  a  phthisical  patient  is  usually  tuber- 
cular. 

2.  Non-gonorrhoeal  cystitis  in  young  persons  is  usually  tubercular. 

3.  Chronic  ulceration  of  the  bladder  is  often  tuberculous. 

4.  As  a  rule  tuberculosis  of  the  bladder  is  part  of  a  urogenital  tuber- 
culosis; in  rare  instances  it  is  directly  secondary  to  tuberculosis  of  the 
lungs  or  intestines. 

Finding  of  the  bacillus  tuberculosis  in  the  urine  or  tissues  is  the 
only  absolute  diagnostic  sign;  to  obtain  tissues  for  microscopical  exami- 
nation, curette  the  ulcerated  surfaces  through  the  endoscope.  The 
smegma  bacillus,  which  has  the  same  minute  appearance  as  the  tubercle 
bacillus,  may  give  rise  to  confusion  in  diagnosis.  The  former  are 
decolorized  by  acid  more  than  the  latter. 

Treatment  of  Cystitis 

The  treatment  of  cystitis  falls  under  four  heads: 

1.  Prophylactic. 

2.  Medicinal. 

3.  Topical. 

4.  Surgical. 

Prophylaxis. — Numerous  autopsies  upon  subjects  who  have  not 
suffered  from  cystitis  have  shown  a  hypersemic  state  of  the  bladder  so 
marked  that  it  must  have  been  of  long  duration,  yet  had  not  developed 
to  the  extent  of  infection  and  inflammation.  The  explanation  must  be 
that  the  infective  element  had  not  been  present,  or  if  present  had  not 
become  active.  On  the  other  hand,  the  question  has  been  raised, 
and  usually  answered  in  the  negative,  whether  the  mere  presence  of 
infection  microbes  alone,  bacillus  tuberculosis  and  gonococcus  excepted, 
can  easily  provoke  cystitis.  It  is  agreed  commonly  that  infection  must 
depend  usually  upon:  first,  an  abnormal  condition  of  the  soil  which 
renders  it  susceptible;  second,  upon  the  presence  of  the  bacterial  ex- 
citing cause.  A  twofold  indication  is  obvious:  to  keep  the  bladder 
in  a  state  of  resistance  and  to  avoid  the  introduction  of  infective 
material.^ 

Susceptibility  to  infection  may  result  from  either  systemic  or  local 
states.     The  systemic  conditions  are  often  the  result  of  faulty  elimi- 

1  Adaptation  from  Kolisher. 


CYST/TIS 


341 


iKitioii  and  consequent  defectixc  circulation.  llcj)atic  and  cardiac  dis- 
orders, kidney  insufriciency,  constipation,  f^ont,  litlueniia,  cliolieinia, 
ana'uiia,  diabetes,  and  rheuniatisni,  at  once  suj^j^^'st  tlienisel\es  as  l'a\-(jr- 
iufj  conditions  callinfi;  for  hygienic  and  medical  treatment,  for  judicious 
elimination  and  initrition.  At  the  risk  of  seeming  to  advocate  routine 
measures,  one  may  sn<i:ij;est  the  value  of  mercurials  and  salines.  It  is 
clearly  es.sential  to  enforce  judicious  rules  for  food,  exercise,  and  sleep. 


Conjoined  examination  of  tubercular  cystitis. 


The  introduction  of  the  catheter  under  the  sheet,  its  passage  with- 
out preparatory  disinfection  of  the  vulva,  the  careless  use  even  of  the 
aseptic  catheter  and  the  slight  traumatism  which  its  use  may  cause, 
and  the  almost  certain  ingress  of  septic  matter  through  such  traumatism, 
are  well  known  to  every  observing  physician.  But,  unfortunately, 
many  physicians,  although  cognizant  of  the  facts,  are  not  alive  to  the 
importance  of  them. 

The  possible  relations  of  parturition  to  cystitis  are  most  significant; 
among  such  relations  are  those  which  arise  from  certain  pelvic  defects. 
For  example,  contraction  or  excessive  inclination  of  the  pelvis  may 


342      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED   DISORDERS 

retard  or  obstruct  labor,  and  thereby  cause  prolonged  pressure  of  the 
child  upon  the  bladder,  giving  rise  to  conditions  full  of  danger. 

Gestation  in  a  retroflexed  uterus  finally  enlarges  the  uterus  until  it 
becomes  impacted  under  the  sacral  promontory;  then  pressure  of  the 
cervix  upon  the  neck  of  the  bladder  produces  oedema,  forces  the  bladder 
against  the  pubes,  prevents  complete  evacuation,  and  results  in  the 
retention  of  residual  urine.  This  urine  may  become  decomposed,  and 
is  then  a  most  favorable  culture-medium  for  bacteria.  If  there  be 
present  in  combination  the  three  elements,  congestion,  decomposed 
residual  urine,  and  bacteria,  even  though  anyone  alone  might  be  in- 
effective, infection  is  almost  unavoidable.  The  necessity  for  prompt 
replacement  of  the  displaced  gravid  uterus,  therefore,  is  clear. 

Postoperative  Cystitis,  that  is,  cystitis  following  surgical  operations, 
especially  Perineorrhapihy,  is  quite  usually  attributed  to  the  use  of  the 
unclean  catheter  or  to  the  unclean  use  of  the  catheter.  While  this  may 
explain  the  causation  in  many  cases,  it  must  be  recognized  on  the  con- 
trary: 1.  That  post-operative  cystitis  occurs  in  the  absence  of  cathe- 
terization. 2.  It  occurs  in  cases  in  which  catheterization  has  been 
aseptic.  3.  The  very  ordinary  practice  of  administering  opiates  to 
relieve  pain  after  operations  often  impairs  the  expulsive  function  of  the 
bladder-wall,  and  results  in  the  retention  of  residual  urine  after  each 
urination.  4.  This  residual  urine  becomes  decomposed  and  is  there- 
fore a  favorable  medium  for  the  development  of  bacteria  and  consequent 
infection.  Therefore,  the  catheter  instead  of  being  contraindicated 
as  a  possible  source  of  cystitis  really  is  indicated  because  only  by  this 
means  can  complete  emptying  of  the  bladder  be  insured  if  opiates  are 
used.  5.  The  most  prophylactic  measure  against  postoperative  cystitis, 
if  opiates  are  used,  is  emptying  the  bladder  completely  at  least  once 
in  twenty-four  hours  by  a  catheter,  and  following  each  catheterization 
immediately  by  irrigation  of  the  bladder  with  a  saturated  solution  of 
boric  acid. 

Medical  Treatment. — The  medical  treatment  already  discussed 
as  a  part  of  the  prophylaxis  has,  especially  in  connection  with  other 
forms  of  treatment,  great  value.  The  principles  are  necessarily  those 
of  general  internal  medicine.  The  particular  indications  have  refer- 
ence to  the  use  of  such  drugs  as  may  change  the  quality  or  increase 
the  quantity  of  the  urine.  If  the  urine  is  strongly  acid  or  concen- 
trated, for  example,  it  should  be  diluted  by  the  free  drinking  of  fluids 
or  rendered  less  acid  by  the  use  of  alkalies;  if  alkaline,  the  reaction 
may  be  modified  by  the  use  of  acids.  Lest  there  be  frequent  urina- 
tion during  the  night,  the  drinking  may  be  confined  largely  to  the 
morning  and  afternoon  hours.  To  secure  a  proper  degree  of  acidity, 
benzoic  acid,  alone  or  combined  with  borax  and  dissolved  in  cinnamon- 
water,  is  a  classical  and  useful  remedy.  The  indication  to  relieve  sub- 
jective symptoms  is  twofold:  first,  to  allay  suffering  and  nervous 
irritation;  and  second,  to  render  the  patient  less  intolerant  of  topical 
and  surgical  treatment. 

In   superficial  mild   cystitis,   with   frequent  urination   and   painful 


CYSTITIS 


M'A 


contractions  of  tlie  l^huldcr,  proin])!  relief  sometimes  follows  the  daily 
aj)plication  of  a  rectal  suppository  eoiitaiiiin<,f  two  or  three  fi;raiiis  of 
iehthyol.  In  more  aj,'<j;ra\ate<l  cases  ojiiiim  ina\'  he  substituted  for 
ichthyol.  To  secure  jijood  sleep,  let  the  iehthyol  suppositories  be  used 
two  or  three  hours  before  bedtime,  and  followed  if  necessary  by  the 
opium  or  morphine  suppositories  at  bedtime. 


Figure  100 


Washing  out  of  the  bladder.  The  irrigation  may  be  made  repeatedly  by  alternately  raising  and 
lowering  the  funnel:  when  the  funnel  is  raised  the  fluid  flows  into  the  bladder,  when  lowered  it  returns 
to  the  funnel. 

The  bowels  should  be  kept  normally  free  by  mild  laxatives.  Drastic 
cathartics  should  be  avoided.  Uva  ursi,  triticum  repens,  the  benzoate 
salts,  buchu,  eucalyptus,  and  many  other  time-honored  and  classical 
remedies  may  be  useful.  Urotropin  appears  to  be  the  most  valuable 
single  internal  remedy.  It  may  be  given  in  amounts  varying  from 
15  to  30  grains  daily.  The  writer  occasionally  has  been  gratified  at 
the  disappearance  of  irritation  of  the  bladder  after  the  administration, 
three  times  a  day,  for  a  number  of  weeks,  of  calomel  in  doses  of  one- 
tenth  to  one-twentieth  of  a  grain,  supplemented  by  the  free  use  of 


344      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

natural  or  artificial  mineral  waters  or  of  pure  water.  Rest,  especially 
in  the  acute  stage,  is  highly  important. 

Topical  Treatment. — The  washing  out  of  the  bladder  as  a  routine 
procedure  is  not  approved.  Irrigation,  however,  is  indicated  positively 
when  necessary  for  the  removal  of  loose  irritating  shreds  or  other 
foreign  matter. 

The  superficial  forms  of  cystitis  respond  promptly  to  topical  treat- 
ment. If  the  cystitis  is  general  and  superficial,  two  ounces  of  a  10 
per  cent,  emulsion  of  iodoform  in  oleum  sesame  may  be  thrown  into 
the  bladder  with  a  hard-rubber  syringe.  If,  after  two  or  three  appli- 
cations of  the  emulsion,  there  is  sufficient  toleration,  four  ounces  of 
silver  nitrate  solution  may  be  injected  into  the  empty  bladder  and 
immediately  replaced  by  free  irrigation  of  normal  salt  solution.  The 
strength  of  the  silver  solution  should  vary  according  to  the  toleration 
of  it.  Begin  with  1  per  cent,  and  cautiously  increase  the  strength  if 
necessary  even  to  3  per  cent.  The  treatment  may  be  repeated  every 
two  or  three  days.  Oftentimes  two  or  three  mild  injections  will 
effect  a  cure.  Vesical  injections  of  argyrol,  1  to  5  per  cent.,  are  non- 
irritating,  effective,  and  may  be  substituted  for  the  silver  nitrate 
solution  to  advantage. 

In  many  cases  the  infection  is  localized,  and  when  localized  is  con- 
fined usually  to  the  trigone  or  inner  end  of  the  urethra.  The  silver 
application  should  then  be  applied  only  to  the  affected  part.  It  may 
be  used  in  solution  of  any  desired  strength  and  applied  by  means  of  a 
cotton  swab  introduced  through  the  cylindrical  cystoscope  and  kept 
within  bounds  by  the  immediate  instillation  of  salt  solution.  Mild 
infections  in  the  trigone  often  yield  completely  to  a  single  treatment. 
Fissure  cystitis  may  be  cured  promptly  and  permanently  by  this  means, 
but  aggravated  cases  sometimes  require  the  solid  stick.  Accompanying 
urethritis  should  be  treated  simultaneously  with  the  cystitis. 

When  the  infection  has  caused  deep  infiltration  in  the  bladder- 
wall,  as  in  exudative  or  diphtheritic  cystitis,  the  treatment  is  to  be 
conducted  in  two  stages — first,  wash  out  the  bladder  to  remove  the 
shreds  and  other  putrid  material;  second,  apply  the  disinfectant.  In 
washing  out  the  bladder  use  small  quantities  of  fluid  and  repeat  until 
the  fluid  returns  clear;  then  apply  the  disinfectant,  preferably  the 
silver  nitrate. 

If  the  secretion  on  the  bladder-wall  is  mucoid  in  character  and 
stringy,  it  is  better  to  use  normal  salt  solution  than  pure  water.  When 
the  bladder  is  so  painful  as  to  resist  all  efforts  at  treatment  it  may  be 
anaesthetized  with  10-20  c.c.  of  a  4  per  cent,  solution  of  antipyrine. 
15  c.c.  of  a  4  per  cent,  solution  of  novocaine  is  quite  as  efficient  as 
cocaine,  and  unlike  the  latter  drug  is  not  dangerously  toxic.  This 
should  be  left  in  the  bladder  about  twenty  minutes.  If  treatment 
leaves  the  bladder  very  painful,  cupping  or  hot  applications  over  the 
bladder  or  opium  and  belladonna  suppositories  in  the  rectum  are 
indicated. 

Cystitis    with    granulations    or    ulcers    require    a    long    time    for 


CYSTITIS  345 

liealinji;;  for  this  purpose  nothin^^  is  hcttcr  than  silver  nitrate  .solution 
or  the  solid  stick. 

In  ext'oliati\'e  cystitis  any  systemic  cau.se  of  the  disturbance  should, 
if  possible,  be  removed.  The  membrane  when  it  becomes  gangrenous 
should  be  taken  away  by  means  of  forceps.  A  jjermanent  catheter 
should  then  be  inserted  both  for  protection  to  the  bladder  from  the 
results  of  distension  and  for  the  injection  of  antiseptic  solutions.  In 
these  cases  the  systemic  condition  is  grave  and  should  be  treated 
acconlingly. 

Surgical  Treatment. — The  surgical  procedures  in  the  treatment  of 
cystitis  are  as  follows: 

1.  Dilatation  of  the  urethra. 

2.  Vaginal  cystotomy,  also  called  colpocystotomy. 

3.  Curettage  of  the  bladder. 

4.  Lithotrity. 

5.  Extravesical  operations. 

1.  Dilatation  of  the  Urethra. — The  indications  for  this  operation  are 
as  follows : 

A.  To  cure  localized  cystitis  in  the  region  of  the  trigone,  commonly 
called  trigonitis,  and  fissure  at  the  neck,  called  fissure  cystitis.  The 
mode  of  treatment  in  fissure  cystitis  is  doubtless  similar  to  that  of 
anal  fissure  by  dilatation  of  the  sphincter  ani  muscle. 

B.  To  enable  the  operator  to  see  and  treat  surgically  or  topically 
vesical  ulcers,  vesical  hemorrhoids,  small  growths,  and  other  afTections 
of  the  bladder,  and  to  permit  the  crushing  of  stone. 

The  dilatation  is  made  by  means  of  the  urethral  dilator,  Figure  30a. 
In  passing  the  instrument  one  should  note  the  extreme  natural  diameter 
of  the  urethra  and  then  limit  the  dilatation  to  about  twice  this  diameter. 
Further  stretching  is  apt  to  rupture  the  urethrovaginal  wall,  and  may 
cause  permanent  incontinence  of  urine.  A  cystoscope  five-eighths  of 
an  inch  in  diameter,  Chapter  III.,  measures  the  extreme  safe  distension 
of  the  average  urethra.  Exceptional  cases  may  arise  in  which  this 
amount  of  dilatation  could  safely  be  increased  or  in  which  it  might 
be  dangerous.  Whatever  stretching  can  be  done  without  tearing  is 
usually  safe.  The  dilatation  may  be  started  with  the  conical  dilator, 
and  completed  with  the  cystoscope. 

2.  Vaginal  Cystotomy. — This  operation.  Figure  161,  has  for  its  object 
the  formation  of  an  artificial  vesicovaginal  fistula.  It  opens  the  vray 
to  intravesical  topical  treatments  and  operations.  Through  the  fistula 
tumors  may  be  removed  and  diseased  surfaces  cauterized  and  curetted. 
In  chronic  cases  of  great,  long-continued,  and  unrelieved  suffering 
colpocystotomy  has,  by  giving  the  bladder  complete  rest,  furnished 
immediate  and  unspeakable  relief.  The  operation  may  be  palliative 
or  curative.  In  a  certain  proportion  of  cases  the  disease  in  the  bladder 
and  upper  zones  of  the  urinary  tract  is  so  extensive  that  the  operation 
can  only  be  palliative — that  is,  an  anatomical  cure  is  sometimes  im- 
possible. In  some  of  these  cases  the  bladder  is  contracted  perma- 
nently to  the  capacity  of  perhaps  one-half  ounce.    No  one  would  think 


346      INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS 

of  making  a  secondary  operation  for  the  closing  of  the  fistula  under 
such  conditions.  In  many  other  cases  the  artificial  opening  may  be 
only  temporary.  It  gives  the  best  opportunity  for  direct  local  treat- 
ment to  diseased  parts  of  the  bladder,  and  for  a  most  effective  vesical, 
douche,  which  can  be  thrown  in  through  the  urethra  and  allowed  to 
flow  out  through  the  fistula  and  vagina.  Very  many  cases  of  otherwise 
intractable  chronic  cystitis  have  been  cured  by  this  method  with  sub- 
sequent closure  of  the  fistula,  and  the  cures,  if  not  anatomically  com- 
plete, were  at  least  symptomatically  satisfactory.  In  some  cases  the 
much  contracted  bladder  even  may  resume  its  physiological  caliber. 
The  operation  of  vaginal  cystotomy  is  the  device  of  T.  A.  Emmet. 

Operation.  —  The  patient  being  in  Sims'  position,  with  the 
anterior  vaginal  wall  exposed  by  Simon's  speculum,  a  large  sound  is 
introduced  through  the  urethra,  and  its  point  pressed  against  the 
vesical  mucosa  in  the  middle  of  the  long  axis  of  the  vesicovaginal 
septum.  iVn  incision  is  now  made  upon  the  sound  through  the  septum 
with  the  knife  or  scissors.  The  point  of  the  sound  then  will  pass  through 
into  the  vagina.  The  opening  thus  made  is  enlarged  so  as  to  extend 
one  inch  in  the  median  line  of  the  long  axis  of  the  vesicovaginal  septum. 
Its  upper  end  will  be  about  one-half  inch  from  the  anterior  wall  of  the 
cervix  uteri,  and  its  lower  end  the  same  distance  from  the  neck  of  the 
bladder.  The  margins  of  the  vesical  and  vaginal  mucosa  then  are  united 
by  fine  interrupted  catgut  sutures. 

The  accompanying  illustration  shows  a  device  which  renders  the 
operation  both  precise  and  simple;  it  consists  in  the  introduction  of 
a  small  uterine  dilator,  instead  of  the  sound  mentioned  above,  through 
the  urethra  into  the  bladder.  The  curved  blades  of  this  dilator  are 
turned  toward  the  vaginal  wall,  the  points  of  the  blades  are  pressed 
against  the  vesicovaginal  septum  in  the  median  line — that  is,  on  a  line 
through  which  the  bladder  is  to  be  opened.  The  blades  of  the  dilator 
are  now^  slightly  separated,  and  the  septum,  being  thus  fixed,  is  incised 
between  the  blades,  as  shown  in  the  illustration.  The  incision  may  be 
made  by  the  scalpel  or  scissors  with  accuracy  and  without  danger  of 
wounding  the  opposite  wall  of  the  bladder. 

In  some  of  the  less  severe  cases  sufficient  improvement  takes  place 
in  a  few  weeks  to  permit  the  closure  of  the  fistula,  with  permanent 
relief. 

In  the  more  chronic  cases  in  which  the  bladder-walls  are  much 
thickened,  deeply  infected,  disorganized,  and  contracted,  and  particu- 
larly when  the  cystitis  is  complicated  with  pyelitis  and  nephritis,  the 
fistula  should  remain  open,  for  its  closure  will  be  followed  inevitably 
by  relapse. 

If  cystitis  be  complicated  by  stone  in  the  bladder  the  treatment 
may  well  be  an  artificial  vesicovaginal  fistula  (colpocystotomy) ,  instead 
of  a  crushing  operation  through  the  urethra.  The  fistula  is  preferred 
for  two  reasons:  first,  the  crushing  operation  may  involve  an  objection- 
able degree  of  dilatation  of  the  urethra;  second,  the  fistula  is  useful 
as  a  means  of  drainage  for  the  cure  of  the  cystitis.     Colpocystotomy 


CYSTITIS 


347 


ma\'  be  indicated  further  for  the  rein()\;il   of  foreij^n   ho(Hes;  it  also 
furnishes  an  opening  for  tlie  cauterization  or  curettaj^e  of  ulcers. 


l'"l(il  HE     1I>1 


\aginal  cystotomy.  A  dilator  is  passed  through  the  urethra  into  the  bladder,  and  the  blades  of  it 
are  pressed  against  the  vesicovaginal  septum  at  a  point  in  the  median  line  midway  between  the  uterus 
and  urethra,  and  separated.  The  vesicovaginal  .septum  is  incised  by  means  of  the  scalpel  or  pointed 
scissors,  which  are  forced  through  the  .septum  between  the  blades  of  the  dilator.  The  point  for  inci- 
.sion  is  determined  by  the  position  of  the  dilator,  and  can  easily  be  felt  by  means  of  the  index-finger 
in  the  vagina.  In  the  lower  part  of  the  Figure  the  dilator  and  scissors  are  shown  complete,  and  in  the 
position  in  which  they  are  when  the  incision  is  made. 


3.  Curettage  of  the  Bladder  may  be  done  through  the  tubular  cys- 
toscope,  but  better  through  an  artificial  vesicovaginal  fistula.  It  is 
indicated  in  indolent  ulcers,  especially  those  of  tubercular  origin. 

4.  Lithotrity  and  Lithotomy. — A  stone  in  the  bladder  may  be  crushed 
through  the  urethra  or  removed  through  an  artificial  vesicovaginal 
fistula.  A  small  stone  or  other  foreign  body  may  be  removed  entire 
through  the  dilated  urethra.    Prompt  relief  from  cystitis  usually  follows. 

5.  Extravesical  Operations. — Parametritic,  perimetritic,  or  tubal 
abscess  may  by  rupture  into  the  bladder  cause  cystitis.     Incision, 


348     INFECTIONS,  INFLAMMATIONS,   AND  ALLIED  DISORDERS 

evacuation,  and  drainage  of  the  pus-cavity,  or  removal  of  the  pus-sac, 
is  followed  usually  by  prompt  cure. 

As  a  final  stage  in  the  treatment  of  cystitis,  the  bladder  if  contracted 
may  often  be  made  to  return  to  its  normal  size  by  methodical  disten- 
sion with  increasing  quantities  of  salt  solution;  but  this  should  not 
be  undertaken  when  the  cystitis  is  acute. 


PYELITIS    AND    NEPHRITIS 

This  topic  has  a  special  gynecological  significance  in  the  matter  of 
diagnosis  and  treatment  by  means  of  the  cystoscope  and  the  ureteral 
catheter,  which  have  been  described  in  Chapter  III.  The  ureteral 
catheter  is  introduced  into  the  ureter  through  the  cystoscope.  By 
this  means  one  may  wash  out  the  urinary  tract  up  to  and  including 
the  pelvis  of  the  kidney;  as  a  result  of  this  treatment  apparent  cures 
in  cases  of  hydro-ureter  and  pyo-ureter  have  been  recorded. 

To  wash  out  the  ureter  the  patient  is  placed  in  the  knee-breast 
position;  the  ureteral  catheter,  with  a  short  piece  of  rubber  tubing 
attached,  filled  with  a  sterilized  boric-acid  solution,  and  clamped  to 
keep  the  solution  from  running  out,  is  passed  through  the  cystoscope 
into  the  ureter  and  the  cystoscope  withdrawn.  A  sterilized  glass 
funnel,  with  an  attached  rubber  tube  eighteen  inches  long,  is  filled 
with  the  irrigating  solution,  and  the  tw^o  rubber  tubes  are  connected 
by  a  small  glass  tube  with  a  point  sufficiently  fine  to  fit  into  the  tube 
on  the  catheter.  By  raising  the  funnel  above  the  level  of  the  body 
the  fluid  is  made  to  flow  through  the  ureter  into  the  pelvis  of  the 
kidney.  When  the  funnel  is  dropped  below  the  level  of  the  body  the 
fluid  returns;  thus,  by  alternately  raising  and  lowering  the  funnel,  the 
fluid  is  made  repeatedly  to  flow  back  and  forth  and  to  Vvash  out  the 
ureter  and  pelvis  of  the  kidney.  The  fluid  may,  if  desired,  be  changed 
one  or  more  times  during  the  treatment.  The  apparatus  is  similar 
to  that  shown  in  Figure  161. 

Purulent  or  other  accumulations  in  the  ureter  should  be  permitted 
to  run  out  through  the  catheter  before  the  washing  out. 

The  practical  value  of  the  ureteral  catheter  as  a  therapeutic  agent 
remains  to  be  estimated.  The  attempt  to  cure  chronic  infection  in  the 
uterus,  nose,  throat,  and  other  mucous  cavities  by  washing  them  out 
with  various  fluids  has  generally  not  been  followed  with  great  success. 
It  is  probable  that  the  ureter  and  pelvis  of  the  kidney  will  not  be  an 
exception  to  the  rule.  Kelly  puts  forth  a  word  of  wise  precaution  on 
the  urgency  of  making  all  ureteral  manipulations  with  extreme  gentle- 
ness. The  catheter  should  never  be  pushed  up  higher  than  it  will 
pass  readily,  for  such  force  would  injure  the  mucosa  and  might  be 
followed   by   infection. 


PART  III 

TUMOIIS,  TUBAL  PlIECIXANCY,  MALFOli- 

MATIONS 


CHAPTER    XXII 

TOIORS  OF  THE  VULVA  AND  ^'AGIXA 

•  The  vulva  and  vagina  are  much  less  subject  .to  new  growths  and  other 
tumors  than  are  the  uterus  and  its  appendages.  Chief  among  the 
tumors  of  the  ^'ulva  and  vagina  may  be  mentioned  the  following: 

Varix.  Carcinoma.  Lupus. 

Hjematoma.  Sarcoma.  Enchondroma. 

Elephantiasis.  Fibromyoma.  .      Neuroma. 

Papilloma.  Lipoma.  Cysts. 

VARIX 

A'arix  is  not  a  neoplasm,  but  an  aggregation  of  dilated  or  varicose 
veins  in  the  erectile  tissue  of  the  bulbi  vaginse.  The  cause  of  the  varicose 
condition  is  obstruction  to  the  circulation  which  arises  most  frequently 
from  direct  pressure  upon  the  venous  trunks  by  the  gravid  uterus, 
less  frequently  from  pressure  exerted  by  tumors  or  inflammatory 
exudates.  Habitual  constipation,  portal  obstruction,  and  visceral  dis- 
ease may  underly  and  perpetuate  the  disorder,  which  belongs  rather 
to  advanced  than  to  early  life.  The  pathological  appearance  of  the 
enlargement  is  that  of  an  oval,  globular,  or  serpentine  mass,  irregular 
in  form,  of  dark  blue  color,  and  sometimes  equal  in  size  to  a  child's 
head.  Rupture  of  the  distended  veins,  spontaneous  or  traumatic,  if 
external,  may  cause  dangerous  hemorrhage.  Rupture  of  the  mass  into 
the  tissues  gives  rise  to  hfematoma.  The  diagnosis  is  based  upon  the 
appearances  above  outlined  and  upon  temporary  disappearance  of  the 
swelling  on  pressure.  The  treatment  includes  mechanical  support  of 
the  uterus,  if  displaced,  regulation  of  the  bowels,  removal  of  waist 
constriction,  the  application  to  the  varix  of  a  pad  held  in  place  by 
a   T-bandage,  the  use   of   astringent   lotions,   and,   especially  during 

22  (349) 


350  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

pregnancy,  frequent  rest.  The  radical  surgical  treatment,  obliteration 
of  the  veins,  is  the  same  as  would  be  indicated  by  the  general  principles 
of  surgery  for  varix  in  any  other  part. 

HEMATOMA 

Hsematoma,  a  common  result  of  varix  or  of  traumatism  independent 
of  varix,  is  an  extravasation  of  blood,  not  a  new  growth.  The  tumor  may 
develop  rapidly  or  slowly  even  to  the  size  of  an  orange,  is  commonly 
unilateral,  globular,  elastic,  and  of  a  violet  color.  It  is  distinguished 
from  pudendal  hernia  by  the  absence  of  impulse  on  coughing  and  by 
non-reduction  on  taxis;  it  may  terminate  by  absorption  or  by  suppura- 
tion, or  the  blood-clot  may  become  encysted.  The  treatment  in  the 
early  stage  is  to  arrest  bleeding  by  means  of  pressure  and  the  ice-bag. 
If  an  abscess  develops,  it  should  be  opened  freely  and  drained.  A 
cyst-wall,  if  formed,  should  be  dissected  out  and  the  wound  closed  by 
deep  sutures. 

ELEPHANTIASIS— PACHYDERMIA 

Elephantiasis  appears  as  a  tumor  of  the  vulva,  of  which  the  general 
appearance  is  presented  in  the  accompanying  illustration. 

Etiology. — The  chief  predisposing  etiological  factor  is  climatic,  the 
disease  being  rare  in  temperate,  common  in  tropical  climates,  and 
epidemic  in  low-lying  countries  along  sea-coasts,  especially  the  islands 
of  the  tropics.  The  growth  is  most  frequent  between  the  years  of 
puberty  and  the  menopause.  The  exciting  cause,  an  organism  called 
the  filaria  sanguinis  hominis,  is  found  early  in  the  disease  in  the 
lymph- vessels  of  the  affected  part;  later,  when  the  vessels  are  blocked 
by  fibrous  deposit,  it  may  disappear. 

Pathology. — In  gross  pathological  appearance  the  growth  may  be 
large  or  small.  Cases  of  twenty  years'  duration  have  been  recorded  and 
the  enlarged  labia  have  been  known  to  reach  the  enormous  weight  of 
fifty  pounds.  Most  frequently  both  labia  are  involved  simultaneously, 
frequently  the  clitoris  and  least  frequently  the  nympha^.  The  growth 
when  large  is  apt  to  be  quite  loose  and  pendulous.  The  disease  is  char- 
acterized by  chronic  recurring  lymphangitis  with  associated  hyper- 
plasia of  the  skin  of  the  vulva  and  the  subcutaneous  connective  tissue. 
The  surface  may  be  rough,  smooth,  viscid,  or  warty.  Ulceration  is 
common  as  the  result  of  friction  and  if  present  gives  rise  to  a  sero- 
albuminous  exudate,  which  may  be  so  profuse  as  to  demand  frequent 
change  of  clothing.     Chyluria  is  a  frequent  complication. 

The  Diagnosis  will  depend  upon  the  presence  of  the  pathological 
conditions  above  described,  and  if  the  growth  be  large  is  unmistakable 
from  the  gross  appearance.  The  finding  of  the  specific  organism  filaria 
sanguinis  hominis  is  positive  proof  of  the  existence  of  the  disease. 
Elephantiasis  is  disabling  from  mechanical  interference  with  urination, 
walking,  and  coitus,  but  does  not  directly  impair  the  general  health. 


TUMORS  OF   THE   VULVA   AND   VAGINA 


351 


The  (lij'crcittidi  (liiKiiiitsi.s  from  (>])it  liclioma,  carcinoiiui,  sarcoma, 
fihronia,  lii)()iiia,  and  lii])iis  ordinarily  should  not  he  difficult  if  close 
attention  is  >;i\cu  to  the  patholoj^ical  and  clinical  outline  of  the  preced- 
ing paragraphs,  supplemeuted  by  the  microscopical  findings.  I'nlike 
elephantiasis,  all  these  growths  are  relatively  free  from  induration  of 
tlie  surrounding  skin.  Lupus,  that  is,  tubercular  vulvitis,  presents 
more  extensive  ulcerations,  deeper  induration,  darker  color,  is  prone 
to  cicatrize,  and  has  for  its  essential  factor  the  tubercle  bacillus. 


Elephantiasis  of  vulva. 


The  Treatment  is  excision.  The  numerous  dilated  lymph-channels 
increase  the  danger  of  septic  infection,  and  in  the  operation  render 
the  most  extreme  asepsis  imperative.  The  operation  is  similar  to  that 
described  for  kraurosis  and  pruritus  vulvae. 


PAPILLOMATA,    CONDYLOMATA,    OR   WARTS 

AYarty   growths   are   epithelial   in  type   and   are   characterized   by 
hypertrophy  of  the  papillae  of  the  skin  or  mucous  membrane,  increase 


352 


TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


of  connective  tissue,  and  thickening  of  the  epithehal  covering.    They 
are  divided  into  three  classes: 

1.  Non-specific,  called  simple  papillomata  or  ordinary  warts. 

2.  Gonorrhoeal — condylomata   acuminata — pointed   condylomata, 

specific  vegetations,  or  venereal  warts. 

3.  Syphilitic — flat  condylomata,  i.  e.,  condylomata  lata. 


Figure  163 


'MM^Ot 

i 

m^^k 

M    '      ^^mI 

^S0^f 

^-^^^'#^1 

^l^p^^pr^j^H 

''^^T    -i^r 

^^y?"    r 

-.■^-^ 

.■ .    _^p 

Simple  warty  vegetations  of  the  vulva. 


1.  Non-specific,  Simple  Papillomata,  or  ordinary  warts,  are  found 
not  uncommonly  on  the  mons  veneris,  less  frequently  on  the  labia. 
They  are  of  unknown  origin,  usually  of  dark  brown  color,  are  not 
deeply  divided,  may  have  a  broad  base  or  may.be  pedunculated,  and 
are  not  apt  to  coalesce  into  large,  compact  masses. 

The  Treatment  is  excision  w^ith  the  sharp  curette  and  cauterization 
of  the  base. 

2.  Gonorrhoeal  Warts — that  is,  warts  associated  with  gonorrhoea — 
are  found  on  the  vulva,  vagina,  cervix  uteri,  perineum,  and  about 
the  anus.  These  warts  occur  singly,  in  groups,  or  in  cauliflower-like 
masses.     The  growths  may  be  so  large  as  to  interfere  with  coitus, 


PLATE    XII 


Enormous  warty  developments  about  the  vulva.  These  growths  were  so  extensive  that 
after  the  removal  of  them  it  was  impossible  to  draw  the  skin  over  the  exposed  surfaces  and 
recourse,  therefore,  was  had  to  the  device  set  forth  in  the  plastic  operation  described  in  the 
following  Plate.     .\uthor's  operation.     (.Surgery,  Gynecology,  and  Obstetrics,  June,'  1906.) 


PLATE    Xlll 


In  order  to  cover  the  exposed  surfaces  made  by  the  removal  of  the  growth  shown  in  the 
preceding  Plate,  deep  lateral  incisions  are  made,  as  shown  in  the  upper  figure  by  the  dotted 
hnes  A  B,  A  C,  D  E,  F  E.  The  space  included  in  the  triangles  ABC  and  D  E  F  are  slid 
inward  toward  the  vulva  and  the  wounds  are  closed,  as  shown  iji  the  lower  figure.  The  same 
device  is  useful  also  in  closure  of  the  completely  lacerated  perineum,  when,  as  sometimes 
occurs,  so  much  tissue  has  been  destroyed  as  to  prevent  easy  approximation. 


PLATE    XIV 


^ 


v^'*^ 


^' 


Microscopic  Section  of  a  Uterine  Myoma. 

The  upper  part  of  this  figure  contains  few  muscle  cells  and  much  fibrous 
stroma  (fibromyoma).  The  remainder  of  the  field  shows  an  abundance  of  muscle 
cells  and  relatively  spe9.king  a  small  amount  of  fibrous  stroma  (myofibroma). 
In  the  lower  half  of  the  picture  the  spindle  cells  are  arranged  in  whirls.  Just 
above  these  whirls  is  a  densely  packed  mass  of  spindle  cells  the  nuclei  of  which 
are  cut  longitudinally,  and  just  above  this  mass  is  a  belt  of  cells  the  nuclei  of 
which  appear  circular  in  shape  because  they  are  cut  transversely.  From  a  histo- 
logical point  of  view  a  uterine  myoma  may  have  all  the  microscopic  appearance 
of  normal  uterine  tissue.  This  drawing  in  different  parts  illustrates  normal  uterus 
tissue,  fibromyoma,  and  myofibroma.      100  diameters. 


TUMORS  OF   rilK    VULVA   AND   VAGINA  353 

urination,  or  defecation;  they  present  a  snrfaee  wliicli  is  soft,  moist, 
of  hhiisli  color,  anil  (U\itle(l  into  small  nodules  with  pointed  ends  like 
a  eoek's  eonih;  when  they  occur  durini;-  pregnancy  they  de\elop  rai)idly, 
hut  may  disa})pear  promptly  after  labor.  There  is  usually  an  associated 
fetid  Na^initis.  The  question  has  been  raised  whether  this  form  of  con- 
dyloma may  not  occur  independently  of  the  gonococcus,  but  cliniqal 
evidence,  including  the  results  of  bacteriological  studies,  strongly 
points  to  at  least  a  coexistent  gonorrluea  as  a  contributing  cause. 

The  Treatment  includes,  first,  thorough  cleansing  and  disinfection 
of  the  diseased  region;  second,  removal  of  the  so-called  vegetations 
with  scissors,  and  cauterization  of  the  base;  third,  antiseptic  dressing 
and  washes  until  the  parts  have  healed.  The  danger  of  puerperal 
sepsis  and  ophthalmia  of  the  newborn  infant  strongly  suggests  radical 
measures  during  pregnancy.  The  a-rays  are  among  the  most  recent 
and  effective  means  of  treatment. 

3.  Syphilitic  Flat  Condylomata — modified  mucous  patches — are  of 
syphilitic  origin  and  may  involve  large  surfaces  of  the  vulva  and  vagina. 
They  are  soft,  grayish,  have  a  broad  base,  and  should  be  treated  by 
disinfectant  applications  locally  and  specific  treatment  generally. 


CARCINOMA  OF  THE  VULVA 

Carcinoma  of  the  vulva  as  compared  with  that  of  the  uterus  is 
quite  infrequent.  It  may  occur  in  either  one  of  two  forms:  1.  Pave- 
ment-cell carcinoma,  commonly  called  epithelioma.  2.  Cylindrical-cell 
carcinoma — adenocarcinoma. 

The  Etiology,  generally  speaking,  is  unknown.  Epithelioma  is  apt 
to  attack  such  orificial  openings  as  the  vulva  where  skin  and  mucous 
membrane  meet.  I  have  had  a  case  of  adenocarcinoma  of  the  vulva 
a  few  weeks  after  the  removal  of  an  adenocarcinomatous  uterus,  during 
which  operation  the  disease  doubtless  was  transplanted  to  the  vulva. 
Prompt  excision  of  the  growths  was  followed  b\"  cure  until  carcinoma 
recurred  two  years  later  in  the  uterine  scar. 

Pathology. — Pavement-cell  carcinoma  may  be  described  as  beginning 
in  a  small,  hard,  whitish,  rough,  friable,  painless,  wart-like  excrescence 
situated  at  any  point  on  the  vulva,  but  more  commonly  between  the 
labia  majora  and  minora;  first  a  gradual  involvement  of  the  super- 
ficial structures  around  the  growth,  then  rapid  ulceration  and  more  or 
less  pain.  The  margins  of  the  ulcer  are  elevated,  hard  and  of  bluish 
color.  The  base  is  granular  and  covered  by  a  semi-opaque  putrid  secre- 
tion. The  inguinal  glands  on  the  corresponding  side  are  involved 
early.  In  cylindrical-cell  carcinoma,  as  compared  with  the  pavement 
form,  the  swelling  begins  more  deeply  in  the  underlying  cellular  tissue 
and  is  characterized  by  more  acute  development,  more  rapid  progress, 
more  profuse  and  more  frequent  hemorrhage,  more  ichorous  discharge, 
earlier  involvement  of  the  inguinal  glands,  more  marked  cachexia, 
more  rapidly  developing  sepsis  and  marasmus,  and  a  much  earlier  fatal 
result. 


354  TUMORS,    TUBAL   PREGNANCY,    MALFORMATIONS 

Diagnosis. — Tentative  diagnosis  made  on  gross  appearance  and 
clinical  history,  as  above  outlined,  usually  is  not  difficult.  Positive 
diagnosis  by  microscopical  examination  will  disclose  not  only  the 
presence  of  carcinoma,  but  the  distinction  between  pavement-cell  and 
cylindrical-cell  carcinoma. 

FlGT-RE     164 


Carcinoma  of  the  vulva. 

Treatment. — The  growth  should  be  excised  radically,  if  possible, 
before  glandular  involvement  and  removal  of  inguinal  glands  whether 
involved  or  not.  Like  operations  for  carcinoma  in  other  parts  of  the 
body  the  prognosis  for  permanent  cure  is  immeasurably  better  in 
epithelioma  than  in  adenocarcinoma  The  prospects  of  permanent 
cure  are  much  increased  especially  in  epithelioma  by  thorough  and 
prolonged  use  of  the  a^-ray  after  excision. 


SARCOMA  OF  THE  VULVA 

Sarcoma  is  of  mesoblastic  origin  and  is  so  rare  in  the  vulva  as  to 
preclude  accurate  description.    The  possible  varieties  are:  first,  round 


Ti'MORS  OF   THE    VLLVA    AM)    r.K,7.V.4  355 

cell;  second,  spindle  cell;  third,  myxosarcoma;  fourth,  melanosarcoraa. 
They  preferably  develop  in  the  labia  majora,  but  have  been  found  in 
the  nymphie.  The  growth,  according;  to  the  variety,  may  be  slow, 
with  late  ulceration;  or  rapid  with  early  and  destructive  ulceration 
and  i)reakini;  down.  The  usual  characteristics  of  sarcoma  of  the  vulva 
are  rapid  ^^rowth,  ulceration  and  variable  hemorrhages.  The  systemic 
breakdown,  though  more  rapid  and  marked,  resembles  that  of  carci- 
noma. All  recorded  cases  have  terminated  fatally.  Death  usually 
results  from  prompt  involvement  of  distant  organs  through  the  venous 
current.  The  treatment  is  removal  at  the  earliest  possible  date.  The 
author  here  records  a  successful  operation  with  no  recurrence  done 
more  than  twenty-five  years  ago  for  the  removal  of  a  spindle-cell 
sarcoma  of  the  mons  veneris. 

CYSTS  OF  THE  VULVA 

The  pathology  of  cysts  of  the  vulvovaginal  glands  has  been  ex- 
plained in  Chapter  XL,  under  Inflammation  of  Bartholin's  Glands. 
The  only  satisfactory  treatment  of  such  a  cyst  is  to  open  the  sac,  dis- 
sect out  the  sac-wall,  and  close  the  wound  with  sutures.  Sebaceous 
cysts  occasionally  have  been  observed.    ~ 

FIBROMYOMA  OF  THE  VULVA 

Fibromyoma  belongs  to  the  connective-tissue  group  of  benign 
tumors,  and  is  therefore  of  mesoblastic  origin.  It  is  composed  of 
fibrous  connective  tissue  and  a  variable  amount  of  muscular  fibres. 
The  histological  characters  of  fibromyoma  will  be  given  more  fully 
under  the  subject  of  Fibromyoma  of  the  Uterus.  The  tumor  is  com- 
monly small,  or  if  large  may  be  pedunculated;  is  not  adherent  to  the 
skin,  and  according  to  the  amount  of  fluid  in  the  interspaces  may  be 
hard  or  soft;  it  often  is  ulcerated  from  friction,  but  is  rarely  the  seat 
of  an  abscess.  The  symptoms  are  mechanical,  usually  due  to  weight 
and  pressure. 

The  treatment  is  excision. 

LIPOMA— FATTY  TUMOR  OF  THE  VULVA 

Lipoma  is  composed  of  lobuli  of  adipose  tissue  in  a  fibrous  mesh- 
work,  and  originates  in  the  fatty  tissue  of  the  labia  majora  and  mons 
veneris.  It  is  distinguished  from  fibromyoma  by  greater  rapidity  of 
gro^\-th,  by  the  lobulated  surface,  and  by  a  peculiar  sensation  to  the 
touch.  This  sensation  is  such  as  would  be  expected  from  a  wad  of 
cotton  under  the  skin.  Lipoma  may  grow  to  the  weight  of  ten  pounds, 
may  extend  to  the  knees,  and  may  be  pedunculated;  it  has  been  mis- 
taken for  hernia. 

The  treatment  is  excision. 


356  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


TUBERCULOSIS— LUPUS 

Lupus,  from  the  pathological  point  of  view,  should  be  classed  as 
tubercular  inflammation.  The  tumor-like  mass,  however,  presents 
physical  characteristics  in  common  with  certain  tumors,  and,  therefore, 
is  introduced  here  from  the  clinical  and  diagnostic  points  of  view.  See 
Tubercular  Vulvitis. 


ENCHONDROMA  AND  NEUROMA  OF  THE  VULVA 

Enchondroma  and  neuroma  are  surgical  curiosities.  Simpson^  has 
reported  the  only  authentic  case  of  neuroma.  Schneevogt  and  Bar- 
tholin have  each  recorded  a  case  of  enchondroma. 


CYSTS  OF  THE  VAGINA 

Vaginal  cysts,  though  not  common,  are  the  most  frequent  of  the 
tumors  originating  in  the  vagina;  they  are  probably  from:  1,  the 
embryonal  remains  of  Gaertner's  (Wolffian)  ducts;  or,  2,  from  diver- 
ticula of  Mueller's  ducts.  An  echinococcus  cyst^  has  been  reported. 
Embryonal  vaginal  cysts  are  usually  not  larger  than  a  walnut,  although 
Veit  has  reported  one  as  large  as  a  foetal  head.^  They  are  circumscribed, 
tense,  elastic,  rarely  pedunculated,  and  commonl^^  unilocular;  they 
occur  singly,  or  in  rare  instances  are  arranged  in  groups  of  two,  three, 
or  four  in  a  row.  The  cyst-wall  is  composed  of  fibrous  tissue,  with  an 
inner  lining  of  cylindrical  or  pavement  epithelium  and  an  outer  covering 
of  vaginal  mucous  membrane.  The  contents  are  commonly  viscid, 
transparent,  and  of  a  pale-yellow  color.  The  occasional  chocolate 
color  is  explained  by  the  presence  of  blood,  pus,  and  epithelial  cells. 

The  differential  diagnosis  is  from  cystocele,  rectocele,  emphysema- 
tous vaginitis,  and  vaginal  hernia.  Cystocele  is  demonstrated  or 
excluded  by  the  sound  in  the  bladder  and  the  finger  in  the  vagina; 
rectocele  by  one  finger  in  the  rectum  and  another  in  the  vagina.  The 
cysts  of  emphysematous  vaginitis  contain  gas,  are  usually  multiple, 
and  do  not  follow  the  course  of  Gaertner's  ducts.  The  hernial  tumor 
temporarily  disappears  on  pressure  and  gives  an  impulse  on  coughing. 

Treatment. — If  the  ,cyst  is  within  easy  reach,  the  treatment  is  ex- 
cision; if  it  is  very  close  to  the  rectum,  bladder,  or  ureters,  the  vaginal 
side  should  be  removed,  the  remainder  curetted  or  cauterized,  and  the 
wound  packed  with  gauze. 

'  Sutton.     Tumors,  Innocent  and  Malignant. 

2  Porak.     Arch,  de  Tocologie,  1884,  p.  163.  . 

3  Pozzi.     Medical  and  Surgical  Gynecology. 


TUMORS  OF   TUh:    \  f  LV A    AND   VAGINA 


357 


FIBROMYOMA  OF  THE  VAGINA 

Fibromyoraata  of  tin*  va<;ina  differ  in  no  essential  point  from  similar 
•rrowtlis  ()f  the  vuha  and  uterus.  They  are  of  rare  occurrence,  and 
usually  small,  hut  sometimes  are  large  enough  to  give  the  mechanical 
symptoms  of  pressure  and  weight.     The  firatmcnt  is  enucleation. 


I  KE     1(15 


Vaginal  cysts. 


CARCINOMA  AND  SARCOMA  OF  THE  VAGINA 

Carcinoma  of  the  vagina  usually  occurs  by  extension  from  primary 
carcinoma  of  the  cervix,  uterus,  or  rectum;  it  rarely  originates  in  the 
vagina.     Sarcoma  of  the  vagina  is  almost  unknown. 

The  treatment — excision — gives  most  unsatisfactory  results. 


CHAPTER  XXIII 

TUMORS  OF  THE  UTERUS— MYOMA 

The  uterine  myoma  is  the  most  common  uterine  tumor,  and  like 
the  uterus  is  composed  chiefly  of  fibrous  connective  tissue  and  non- 
striated  muscular  fibres.  The  characteristic  cell  elements  are  non- 
striated  fusiform  muscle  fibres  with  elongated  nuclei  which  may  be 
combined  in  any  proportion  with  fibrous  tissue.  Nothing  is  known 
of  the  histogenesis  of  these  tumors  beyond  the  fact  that  they  originate 
in  the  myoblast,  a  fact  which  stamps  them  as  myomata,  regardless  of 
the  relative  quantity  of  the  muscular  and  connective  tissue.  The  tumor 
does  not  lose  its  identity  as  a  myoma  even  though  all  the  muscular 
elements  have  disappeared  and  been  replaced  by  fibrous  tissue.  A 
soft  vascular  tumor,  because  it  contains  a  large  amount  of  muscular 
tissue,  has  been  called  myofibroma  or  leiomyoma.  The  hard,  more 
fibrous  myoma  often  is  called  fihromyoma  or  fibroma.  There  is  no 
definite  line  between  the  so-called  myofibroma  and  fibromyoma.  The 
terms  are  relative  and,  to  an  extent,  arbitrary,  and  to  be  used  only 
for  convenience  of  description. 

Etiology  of  Myoma 

Myomata  commonly  develop  during  the  period  of  sexual  maturity, 
rarely  if  ever  before  puberty  or  after  the  menopause.  The  impression 
that  they  are  more  common  in  the  negro  than  in  the  white  race  appears 
to  be  disproved  by  the  investigations  of  Howard  Kelly  and  Daniel 
Williams.  Heredity  probably  is  an  etiological  factor.  In  the  older 
literature  they  are  said  to  result  from  traumatism,  but  the  assertion 
is  purely  speculative,  no  evidence  having  been  brought  forward  in 
support  of  it.    The  causes  of  these  tumors  are  not  known. 

Pathology  of  Myoma 

In  most  cases  the  tumor  is  circumscribed  sharply,  is  single  or  multi- 
ple, hard  or  soft,  of  pinkish  or  whitish  color,  commonly  of  slow  growth, 
and  varying  in  size  within  wide  limits.  On  cross-section  it  is  glistening 
and  may  be  homogeneous,  but  usually  is  striated  with  dense  fibrous 
septa  which  divide  the  section  into  lobules.  The  spaces  between  the 
septa  are  filled  with  muscle-fibres.  In  later  development  a  loose  fibrous 
capsule  is  formed  which  sharply  defines  the  growth  from  its  surround- 
ings; and  from  which  the  growth  may  be  shelled  out  readily;  the 
blood-vessels  of  the  fibrous  capsule  penetrate  through  the  septa  to  the 
(358j 


TUMOIiS  OF   rilK   CTEhTS— MYOMA  359 

imisclc-cells.  This  ca|)suk'  is  not  a  part  of  tin-  tumor.  It  is  a  result 
of  the  growth  of  the  tumor.  As  the  tumor  increases  in  size  the  sur- 
rounding inuscuJar  tissue  is  compressed,  atrophy  of  tlie  mu.scle  cells 
occurs,  and  the  connective  tissue  left  behind  becomes  the  capsule. 

These  growths  are  subject  occasionally  to  extensive  venous  obstruc- 
tion and  dilatation  which  often  leads  to  the  formation  of  cavernous 
spaces;  hence  the  blood-supply,  not  only  in  different  tumors,  but  at 
dift'erent  times  in  the  same  tumor,  is  subject  to  great  variation.  This 
changeable  blood  supply  accounts  for  corresponding  variation  from 
time  to  time  in  the  size  of  a  tumor.  Hard  white  tumors  of  a  slow  growth, 
containing  a  relatively  large  amount  of  fibrous  tissue,  are  apt  to  ha\e  a 
limited  blood-supply.  On  the  other  hand,  the  soft  pinkish  tumor  of 
more  rapid  growth,  with  a  relative  preponderance  of  muscle-cells,  is 
always  more  vascular. 

The  secondary  changes  common  to  uterine  myoma  are: 
Fatty  generation.  Septic  infection. 

^Mucoid  degeneration.  jNIalignant  changes. 

Calcification.  Gangrene,  i.  e.,  necrosis. 

Fatty  Degeneration  pertains  to  the  muscle-fibres  and  may  destroy 
them  completely,  leaving  behind  a  contracting  formation  of  fibrous 
connective  tissue  which  in  the  process  of  solidification  is  apt  to  crush 
out  and  destroy  the  blood-supply  so  that  the  tumor  deprived  of  nutri- 
tion becomes  a  hard  rudimentary  mass;  this  process  is  associated 
frequently  with  similar  atrophic  changes  in  the  uterus  during  the 
menopause,  and  explains  numerous  spontaneous  cures  occurring  at 
this  period,  especially  of  small  tumors. 

Mucoid  Degeneration,  usually  preceded  by  oedema  and  rapid  increase 
in  the  size  of  the  tumor,  occurs  principally  in  large  fibromyomata,  and 
is  characterized  by  the  conversion  of  the  fibrous  tissue  into  mucous 
substance  resembling  the  vitreous  humor  of  the  eye.  The  structures 
which  form  the  boundary  "of  the  softened  spaces  may  show  every 
gradation  from  typical  spindle  cells  to  myxomatous  cells  of  the  spider- 
like  shape.  There  may  be  developed  numerous  small  cysts  in  a  tumor 
or  a  single  large  so-called  fibrocyst  having  for  its  wall  the  fibrous 
capsule  of  the  original  tumor.  See  accompanying  illustration  of  fibro- 
cystic tumor. 

(Edema  may  cause  so  much  dilatation  of  the  lymph-spaces  as  to  give 
the  whole  tumor  an  appearance  of  marked  cystic  degeneration,  or  the 
dilated  cavernous  veins  already  described  may  be  converted  into  blood 
cysts. 

Calcification  occurs  most  frequently  in  atrophied  subperitoneal 
tumors,  and  may  pertain  to  the  individual  fibrous  septa  or  to  the 
capsule,  or  in  exceptional  cases  the  entire  tumor  may  be  displaced  by 
lime  salts  and  converted  into  a  stone — so-called  womb-stone.  A 
section  of  such  a  stone  made  by  the  saw  will  sometimes  take  high 
polish  with  the  whole  arrangement  of  the  fibrous  septa  and  capsule 
reproduced  in  the  lime  salts.  ^Nlore  commonly  the  spaces  between 
the  septa  do  not  calcify,  but  disappear  by  some  other  degenerative 


360 


TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


process  giving  the  calcified  part  a  porous,  worm-eaten,  or  coral-like 
appearance.  When  the  calcification  is  chiefly  or  whoUy  in  the  fibrous 
capsule  the  tumor  is  covered  by  a  thin  hard  crust  which  may  resemble 
closely  the  foetal  skull.  In  the  enucleation  of  such  a  tumor  from  the 
corpus  uteri  the  writer  once  found  a  calcified  capsule  which  under  the 
thin  wall  of  the  corpus  uteri  felt  so  much  like  a  foetal  head — including 
the  sutures  and  fontanelles — that  he  was  almost  led  to  abandon  the 
operation. 

Figure   166 


Fibrocystic  myoma  uteri.     The  interior  of  the  tumor  shows  the  fibrocystic  changes. 

Septic  Infection. — A  myoma  which  has  for  years  given  rise  to  no 
inconvenience,  may  become  suddenly  infected,  with  rapid  increase  m 
size,  high  pulse  and  temperature,  great  pain,  and  evidences  of  sep- 
ticaemia. The  cause  of  infection,  sometimes  obscure,  is  explained 
usually  by  the  presence  of  one  or  more  of  the  known  causes  of  pelvic 
inflammation,  such  as  electrolysis,  the  unclean  intra-uterine  sound, 
external  violence,  septic  operations,  and  extension  of  infection  from 
an  adherent  intestine  or  bladder.  A  fatal  result  is  almost  inevitable 
unless  the  diagnosis  is  made  early  and  the  tumor  removed. 

Malignant  Changes  Avill  be  considered  in  chapters  on  Carcinoma  and 
Sarcoma. 

The  Location  of  the  tumor  may  be  an}'^vhe^e  in  the  uterine  substance, 
but  in  the  majority  of  cases  it  is  in  the  body  of  the  uterus.  Tumors 
of  the  cervix  uteri  are  apt  to  be  small,  those  of  the  corpus  larger. 


TUMORS  OF   TUK   VTKRUS— MYOMA 


361 


The  regional  classification  as  shown  in  the  accompanying  figure  is: 

1.  Intranniral  (interstitial)  myomata. 

2.  Submucous  myomata. 

3.  Subperitoneal  myomata. 

4.  CtT\ical  myomata. 

Figure  167 


Intramural,  submucous,  and  subperitoneal  rii\oniutu.  A  pedunculated  subperitoneal  myoma 
sometimes  is  called  wrongly  extra-uterine  myoma.  A  pedunculated  submucous  myoma  is  called 
intra-uterine  polypus. 


1.  Intramural  Myomata. — All  myomata  are  primarily  intramural — 
i.  e.,  they  originate  in  the  uterine  wall,  but  the  term  intramural  is  re- 
served here  for  tumors  surrounded  wholly  by  the  muscular  wall  of  the 
uterus.  The  growth  in  most  cases  is  firm,  sharply  defined,  and  en- 
capsulated or  in  exceptional  cases  soft,  ill-defined,  and  without  a  definite 
capsule;  it  has  from  its  situation  an  abundant  blood-supply  on  all 
sides,  and  for  this  reason  may  grow  rapidly  to  large  size.  It  will  always 
irritate  the  surrounding  muscular  tissues  and  cause  them  to  contract 
upon  it  so  that  if  it  is  nearer  to  the  endometrium  than  to  the  peritoneum 
the  preponderance  of  muscular  tissue  on  the  peritoneal  side  may  force 
it  slowly  toward  the  interior  of  the  uterus  and  tend  to  make  of  it  a 
submucous  tumor.    If  the  preponderance  of  muscular  tissue  is  between 


362  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

the  tumor  and  the  endometrium,  the  direction  of  least  resistance  will 
be  toward  the  peritoneum,  and  the  growth  will  tend  to  become  sub- 
peritoneal. The  same  uterus  may  contain  one  or  many  intramural 
tumors. 

Figure  168 


Intramural  myomata.     The  lower  tumor  exerts  pressure  on  all  the  pelvic  organs.     The  upper  tumor 
displaces  the  uterus  upward  by  traction. 

2.  Submucous  Myomata  may  originate  in  the  muscular  tissue  of 
the  submucosa,  and  be,  therefore,  primarily  submucous;  or  an  intra- 
mural tumor,  as  explained  in  the  preceding  paragraph,  may  become 
secondarily  submucous.  The  secondarily  submucous  tumor  is  apt  to 
remain  sessile — i.  e.,  to  have  little  tendency  to  form  a  pedicle.  The 
primarily  submucous  tumor,  on  the  contrary,  usually  develops  a  pedicle. 
The  pedunculated  submucous  myoma  is  vascular,  soft,  commonly  single, 
usually  corporeal,  rarely  cervical,  in  most  cases  small,  but  may  be  large 
enough  to  distend  the  uterus  enormously.  It  may  be  forced  by  uterine 
contractions  through  the  cervix  uteri,  and  the  pedicle  by  the  downward 
traction  of  the  tumor  may  become  much  elongated  so  that  the  extruding 
mass  may  finally  be  forced  through  the  vulva.  The  pedicle  may  be 
constricted  by  pressure  of  the  cervical  canal  or  may  become  twisted 


TUMORS  OF   THE   UTERUS—MYOMA 


363 


witli  C()ns('(iiic'iit  naii'j.riMic  of  the  tumor  and  consequent  sjjontaneous 
(letachnient  and  cure,  l)ut  not  uiiconiuionly  the  extruded  mass  remains 
(inlematous  and  hemorrhagic,  a  menace  to  health  or  a  destroyer  of  Hfe. 
Adhesions  may  form  between  an  intra-uterine  tumor  and  the  endo- 
metrium or  cervical  mucosa,  and  by  partial  or  complete  oblitenition 
of  the  uterine  cavity  lock  the  secretions  within  the  uterus. 

Figure  109 


jMultiple  myomata,  suitable  for  vaginal  hysterectomy. 


3.  Subperitoneal  Myomata — sometimes  called  subserous — may  be 
either  single  or  multiple,  and  occasionally  may  reach  the  enormous 
size  of  forty  or  fifty  pounds.  These  tumors,  primarily  intramural, 
have  been  forced  outward  by  uterine  contractions  until  they  become 
secondarily  subserous,  or  such  a  tumor  has  worked  its  way  from  the 
point  of  origin  into  the  territory  between  the  folds  of  the  broad  liga- 
ment, and  become  an  intraligamentous  myoma.  A  pedunculated  sub- 
serous tumor  may,  in  rare  cases,  become  detached  from  the  uterus  and 
remain  as  a   migrating  tumor,  relatively  harmless  in  the  abdominal 


364 


TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


cavity;  or  may  receive  its  nutrition  through  new  adhesions  which  have 
formed  between  it  and  some  of  the  pelvic  or  abdominal  viscera;  or  may 
become  gangrenous  and  give  rise  to  serious  infection;  or  may  atrophy 
and  disappear. 


Figure  170 


Submucous  pedunculated  myoma,  resembling  an  inverted  uterus. 

4.  Cervical  Myomata. — ]Myomata  of  the  cervix  uteri  are  of  rather 
infrequent  occurrence,  follow  the  same  law  as  to  development  and 
location  as  myomata  of  the  body  of  the  uterus,  and  usually  spring 
from  the  supravaginal,  rarely  from  the  infravaginal,  portion  of  the 
cervix.  A  submucous  cervical  myoma  is  usually  pedunculated,  and 
may  have  the  appearance  of  a  uterus  inverted  into  the  vagina.  An 
intramural  cervical  myoma  causes  thickening  of  the  cervical  wall 
around  it  and,  by  pressure  and  stretching,  a  corresponding  thinning  of 
the  opposite  wall. 

Symptoms  of  Myoma 

The  chief  symptoms  are  hemorrhage,  pain,  discomfort,  and  uterine 
discharges. 

Hemorrhage,^  the  most  important  and  the  most  pronounced  symp- 
tom, begins  not  as  a  sudden,  profuse  flow,  as  in  carcinoma,  but  as  a 

'Sampson  (Surg.,  Gyn.,  and  Obst.,  March,  1912,  and  February,  1913)  has  studied  the  blood-supply 
of  myomata  and  the  circulatory  changes  caused  by  them  in  the  uteius.  His  studies  were  based  on 
arterial  and  venous  injection  of  myomatous  uteri,  and  show  that  myomata  are  nourished  by  nutrient 
arteries  and  that  medium-sized  and  large  tumors  are  often  more  vascular  arterially  than  the  containing 
myometrium.  On  the  other  hand,  unlike  the  surrounding  myometrium,  which  is  richly  supplied  with 
venous  spaces,  myomata  usually  contain  very  few  veins. 


TUMORS  OF   THE   UTERUS— MYOMA  365 

fiTadiial  increase  in  menstruation;  the  l)lee(linji,-  occurs  t'rc(jueiitl\ ,  is 
prolonged,  and  may  result  from  ordinary  conditicjiis,  such  as  exercise 
or  coitus.  The  irritating  ])resence  of  the  tumor  predisposes  to  hemor- 
rhagic endometritis,  the  hemorrhagic  area  being  the  endometrium, 
not  usually,  as  sometimes  supposed,  the  tumor  itself.  Fatal  hemor- 
rhage, however,  has  occurred  from  rupture  of  a  blood-vessel  in  the 
growth. 

The  degree  of  hemorrhage  depends  upon  the  location  of  the  tumor 
relative  to  the  endometrium  and  the  peritoneum.  The  closer  to  the 
uterine  mucosa,  the  greater  the  hemorrhage;  the  nearer  to  the  peri- 
toneum, the  less  the  hemorrhage;  hence  menorrhagia  is  almost  invari- 
able with  the  submucous  variety,  less  severe  but  \'ery  common  with  the 
intramural,  and  sometimes  shght  or  absent  with  the  subperitoneal. 
The  pedunculated  submucous  and  the  pedunculated  subperitoneal 
myomata  stand  at  the  two  extremes,  the  former  producing  the  greatest 
hemorrhage,  the  latter  little  or  none  at  all.  Hemorrhage  is  not  always 
proportionate  to  the  size  of  the  tumor;  a  large  tumor  may  obstruct 
the  flow  of  blood,  or  by  pressure-atrophy  of  the  endometrium  may, 
very  exceptionally,  give  rise  to  scanty  menstruation;  on  the  other  hand, 
a  small  submucous  myoma  may  cause  alarming  uterine  hemorrhage. 

A  myoma  often  delays,  prolongs,  or  prevents  the  menopause;  it 
may  participate  in  the  atrophic  processes  of  this  crisis,  and  become 
smaller,  or  disappear;  in  some  cases  the  menopause  has  the  opposite 
eflfect — i.  e.,  great  and  sudden  growth  with  increased  hemorrhages. 
Such  increase  is  e\idence  though  by  no  means  proof  of  malignant 
degeneration  and  offers  therefore  a  strong  indication  for  myomectomy 
or  hysterectomy. 

Pain  and  Discomfort  may  be  caused  by  numerous  mechanical  and 
other  disturbances  of  the  rectum,  bladder,  ureters,  urethra,  and  of  the 
uterus  itself,  such  as  hemorrhoids,  constipation,  rectal  and  vesical 
tenesmus,  mucous  diarrhoea,  frequent  urination,  dysuria,  retention  of 
urine,  and  uterine  displacements.  Pressure  upon  the  venous  trunks 
often  causes  great  dilatation  of  the  veins  and  passive  congestion  through- 
out the  pelvis.  Pressure  on  a  ureter  has  given  rise  to  obstruction  and 
caused  hydronephrosis. 

A  myoma  in  the  anterior  uterine  w^all,  even  though  small,  may,  by- 
pressure,  set  up  extreme  vesical  irritation  with  the  possible  conse- 
quence of  cystitis.  Pressure  from  a  myoma  incarcerated  under  the 
promontory  of  the  sacrum,  unless  the  tumor  spontaneously  or  manually 
is  forced  up  into  the  abdominal  cavity,  will  cause  great  pain  and  inter- 
ference with  functions  not  only  in  the  pelvis,  but  also  in  the  lower 
extremities. 

Uterine  displacements  may  result  from  pressure,  traction,  and 
increased  weight.  A  tumor  situated  above,  below,  to  either  side,  in 
front,  or  back  of  the  uterus  may  force  it  by  pressure  in  the  opposite 
direction,  or  may  draw  it  by  traction  in  the  same  direction,  or,  by 
increasing  the  weight  of  the  uterus,  may  cause  prolapse.  A  myoma, 
for  example,  which  has  grown  too  large  for  the  pelvis  to  hold  it,  and 

23 


366  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

has  therefore  risen  above  the  pelvic  brim  into  the  abdomen,  wih  cause 
upward   displacement   by  traction. 

The  pressure  and  traction  symptoms  include  also  backache,  bearing- 
down,  dragging  sensations  in  the  pelvis  and  dysmenorrhoea.  Expulsive 
contractions  of  the  uterus  upon  a  mural  or  submucous  myoma,  espe- 
cially during  the  period  of  menstrual  congestion  and  irritation,  may 
be  transient  or  constant,  moderate  or  severe. 

Intermenstrual  Uterine  Discharges  caused  by  great  vascularity  of 
the  uterine  mucosa  and  the  hypertrophic  condition  of  the  glands, 
usually  occur  in  the  progress  of  the  disease;  these  discharges  may 
be  purulent  or  serous,  or  both;  are  mixed  commonly  with  blood,  and 
often  are  profuse  and  exhausting.  The  watery  discharge — h}'dror- 
rhoea  —  usually  associated  with  malignant  disease  is  very  infrequent 
in  myoma,  but  when  present  is  more  transient  and  less  offensive 
than  in  cancer  or  sarcoma. 


Diagnosis  of  Myoma 

Uterine  myomata,  unless  very  small  and  associated  with  metritis, 
usualh'  are  not  difficult  to  recognize.  The  symptoms  outlined  in  the 
foregoing  paragraphs,  although  diagnostic,  are  far  from  pathognomonic. 
The  diagnosis  will  depend  always  upon  inspection,  palpation,  conjoined 
examination,  and  exploration  of  the  uterine  cavity.  See  Figures  in 
Chapter  III. 

Inspection  and  Palpation  will  show  enlargement  of  the  abdomen 
unless  the  tumor  is  too  small  to  produce  that  result.  External  palpa- 
tion, if  the  tumor  is  large,  discloses  in  the  pelvis  and  lower  abdomen  a 
solid,  usually  hard,  though  sometimes  soft  mass.  Exceptionally  the 
growth  has  a  peculiar  elasticity  which  resembles  fluctuation,  but  lacks 
the  percussion-wave  peculiar  to  cystic  tumors.  The  tumor  may  be 
single  and  symmetrical,  globular  or  oblong.  The  presence  of  multiple 
myomata  may,  w^ith  their  numerous  projections,  give  to  the  uterus  a 
most  irregular  form.  Many  small  tumors  may  be  distributed  so  evenly 
throughout  the  uterine  walls  as  to  cause  a  nearly  symmetrical  enlarge- 
ment of  the  uterus,  but  in  such  a  case  the  surface  usually  gives  to  the 
touch  a  sensation  of  small  nodular  irregularities.  Inspection,  palpation, 
and  percussion  will  be  considered  further  in  connection  with  differential 
diagnosis. 

Conjoined  Examination. — The  index  or  the  index  and  middle  fingers 
in  the  vagina,  the  palmer  surface  directed  toward  the  uterus  and  tumor, 
and  the  palpating  fingers  of  the  right  hand  over  the  abdomen,  if  the 
abdominal  muscles  are  not  too  tense,  will  enable  the  examiner  to  out- 
line the  uterus  and  its  myomatous  projections.  In  the  majority  of 
cases  ordinary  conjoined  examination  will  complete  the  diagnosis. 
The  palpation  often  is  facilitated  by  means  of  the  thumb  in  the  vagina 
and  the  index-finger  in  the  rectum.  This  enables  the  operator  to  pick 
up,  so  to  speak,  the  enlarged  uterus  between  the  thumb  and  finger. 


TUMORS  OF   THE   UTERUS— MYOMA  367 

Information  through  the  examining  finger  is  obtained  not  so  much 
by  forcing  it  up  against  the  tumor  as  by  strong  pressure  of  the  tumor 
against  it  by  means  of  the  riglit  hand  over  the  abdomen.  If  the  ab- 
dominal walls  are  rigid  or  thick,  anaesthesia  may  be  necessary. 

Conjuincd  Intra-uterine  Examination  with  an  index-finger  in  the 
uterus  anti  a  hantl  over  the  alxlomen  is  possible  only  when  the  uterine 
canal  is  dilated,  a  condition  whicii  may  be  brought  about  by  instru- 
mental means  or  may  result  spontaneously  from  uterine  contractions 
upon  an  intra-uterine  tumor.  The  index-finger  in  the  dilated  uterus  will 
recognize  by  direct  touch  tlie  presence  and  character  of  an  intra-uterine 
growth. 

Exploration  by  the  Sound. — -The  sound  Avill  show: 

The  direction  of  the  uterine  canal. 

The  length  of  the  uterine  canal. 

The  shape  of  the  uterine  cavity. 

The  relations  of  tumors  to  the  uterine  cavity. 
The  one  fact  constant  for  all  uterine  myomata  is  elongation  of  the  ideriyie 
cavity,  the  presence  or  absence  of  which  can  be  ascertained  by  the  sound 
or  probe.  The  increased  length  is  proportionate  to  the  size  of  the  tumor, 
and  may  reach  twelve  or  more  inches.  Unless  care  is  used,  a  submucous 
tumor  may  obstruct  the  passage  of  the  sound  and  lead  to  wrong  meas- 
urement. Submucous  and  intramural  tumors  project  into  the  uterine 
cavity,  and  thereby  render  the  uterine  canal  tortuous,  and  unless  the 
myoma  is  too  soft  and  small  to  be  recognized  the  sound  or  probe  will 
be  deflected,  and  as  it  glides  over  the  growth  the  deflection  will  indicate 
the  size  of  the  growth  and  the  degree  to  which  it  projects  into  the 
uterine  cavity. 

Differential  Diagnosis. — The  principal  lesions  from  which  myoma 
must  be  differentiated  are  the  following: 

Intra-uterine  pregnancy.  Incomplete  abortion. 

Tubal  pregnancy.  Ovary. 

Carcinoma  and  sarcoma.  Pelvic  infiltrations. 

Chronic  metritis.  Pelvic  cysts. 

Uterine  displacements.  Sactosalpinx. 

Floating  kidney. 
Intra-uterine  Pregnancy. — Normal  utero-gestation  will  be  excluded 
by  the  absence  of  the  usual  signs  of  pregnancy.  The  difficulties  in 
diagnosis  will  arise  commonly  in  abnormal  pregnancies,  especially  in 
placenta  prtevia  and  in  pseudo-menstruation  connected  with  preg- 
nancy. If  the  enlargement  of  the  uterus  be  symmetrical  and  the  rate 
of  growth  usual  for  a  pregnant  uterus,  and  the  os  be  soft  and  patulous, 
pregnancy  is  highly  probable.  If,  on  the  other  hand,  the  cervix  be 
hard,  the  os  non-patulous,  and  the  uterus  irregular  in  outline  from  the 
presence  of  a  hard,  resisting  mass,  the  diagnosis  is  probably  myoma. 
The  x-ray  may  give  definite  information.  Not  very  infrequently  myoma 
and  pregnancy  coexist;  then  if  the  tumor  is  large  and  the  foetus  small, 
the  difficulty  of  diagnosis  is  great.  In  doubtful  cases  the  myoma,  if 
present,  will  declare  itself  by  relatively  slow  growth.     The  following 


368  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

tabular   statement   contains   the   chief   points  of  difference   between 
myoma  and  pregnancy: 

Pregnancy  j  Myoma 

1  History  of  pret'naiicy.     Amenorrhoea  usual.   1        1.  Absent.     Uterine  hemorrhage  usual. 

2  Uterus' soft  and  elastic.  I       2.   Usually  irregular  in  form  and  harder. 

3  Uterus  usually  will  contract  and  harden  on   ;        3.   Uterine      contraction     not     marked — very 
palpation.  -  j   '™P°^t^^^^  !J§'i 

4.  Cervix  Soft.  .        . 

0.  Regular    and    uniform    increase    in    size    of 


uterus. 

6.  Later,  ballottement,   fcetal  heart  tones. 

7.  Palpation  of  foetas. 


4.  Hard  or  not  so  soft. 

5.  Growth  slow. 

6.  Absent. 

7.  Palpation  of  myoma. 


Tubal  Pregnancy  gives  a  history  of  gestation.  The  gestation-sac 
closely  resembles  the  sactosalpinx  of  salpingitis.  Rupture  of  the  tube 
produces  pelvic  hsematocele.  A  decidua  may  be  cast  out  of  the  uterus. 
The  reader  is  referred  to  the  decidua  cast  off  in  tubal  pregnancy, 
Chapter  XVI. 

If  tubal  pregnancy  has  resulted  in  pelvic  hsematocele  by  tubal 
rupture  or  tubal  abortion,  the  differential  points  will  be  as  follows: 

Hwmatocele  '.  Myoma 

I 

1.  History  of  pregnancy.  1        1-  Absent. 

2.  Sudden  appearance,  shock,  severe  pain,  and   |        2.  Absent, 
evidence  of  hemorrhage.  ! 

3.  Consistence  of  mass  usually  soft,  later  may  3.   Usually  hard, 
be  hard. 

4.  Not  sharply  outlined.  4.   Sharply  outhned. 

5.  Later,  mass  shrinks  and  becomes  harder  or  o.  Commonly  increases  in  size;  may  decrease 
may  suppurate.                                                                     after  menopause. 

Diagnosis  of  Myoma  Complicating  Pregnancy. — ]\Iyoma  may  be  mis- 
taken for  the  foetal  head,  elbow,  or  knee.  Intramural  myoma  compli- 
cated by  pregnancy  takes  on  rapid  increase  of  growth,  is  softer  than 
formerly,  but  firmer  than  the  pregnant  uterus;  this  variability  in 
consistence  is  almost  proof  of  complicating  pregnancy,  and  calls  for 
repeated  examinations.  Later,  one  may  palpate  the  foetus,  elicit 
ballottement,  and  hear  the  foetal  beat.  Here  the  x-vay  may  give  a 
positive  diagnosis. 

Carcinoma  and  Sarcoma. — The  evidences  of  malignant  disease,  in- 
cluding the  sudden  onset  of  hydrorrhoea,  the  bloody,  fetid  discharge, 
the  rapid  emaciation,  and  the  microscopical  finding  of  carcinoma  or 
sarcoma  in  the  scrapings,  will  exclude  myoma  definitely.  A  sloughing, 
extruding  myoma  may,  however,  both  in  the  profuse  fetid  discharge 
and  in  the  sensation  to  the  examiner  on  touch,  closely  resemble  car- 
cinoma or  sarcoma  of  the  cervix.  The  diagnosis  then  will  depend  on 
the  microscope. 

Metritis  often  complicates  uterine  myomata,  and  is  difficult,  often 
impossible,  to  differentiate  from  small,  multiple,  interstitial  growths. 
The  symmetrical  form  of  the  uterus  is  the  distinguishing  feature  of 
metritis.     See  differential  tabular  statement  below. 

Chronic  metritis  I  Myoma 

1     I'niform  enlargement.  '  1-  Enlargement  usually  irregular. 

2.  Uniform  hardness.  '  2.  I'terus  softer  than  tumor. 

3.  Uterus  not  larger  than  two  or  three  times  '  3.  Size  may  increase  to  thirty  or  forty  pounds, 
the  normal  size. 


TUMORS  OF   THE   UTERUS— MYOMA 


369 


Displacements  of  the  Uterus  arc  recoi^iiizcd  on  conjoined  examina- 
tion by  the  symmetrical  contour  of  the  uterus  and  hy  the  cliange  in 
the  direction  of  the  uterine  canal  as  demonstrated  by  the  sound.  A 
uterine  myoma  protruding  into  the  vagina  may  have  the  appearance 
of  an  inverted  uterus.  The  sound  then  will  glide  j^ast  the  tumor  into 
the  uterus  above.  Conjoined  recto-abdominal  examination  will  demon- 
strate the  absence  of  the  uterus  in  its  normal  location  if  it  be  inverted 
into  the  vagina.     See  Inversion  of  the  Uterus. 

FiGURt;   171 


Myomatous  uterus,   five  months  pregnant.     Infection  of  myoma,   and  consequent  peritonitis  from 
twisted  pedicle.     Hysterectomy.      (Case  referred  by  Dr.  A.  C.  Haven.) 


Incomplete  Abortion  with  hemorrhage  will  be  recognized  by  the 
history  of  interrupted  pregnancy  and  by  microscopical  examination  of 
the  scrapings. 

The  Ovary,  especially  if  the  seat  of  a  solid  tumor  and  adherent  to 
the  uterus,  sometimes  simulates  a  subserous  myoma.  The  myoma, 
however,  is  smoother,  more  firm,  and  less  sensitive  to  pressure. 

Pelvic  Inflammatory  Infiltrations,  unlike  myomata,  always  give  a 
history  of  pelvic  inflammation,  are  very  tender  on  pressure,  immo- 
bile, and  prone  to  disappear  by  resolution  or  to  undergo  suppuration. 
See  Differential  Diagnosis  of  Pelvic  Cellulitis. 


370 


TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


Pelvic  Cysts  are  distinguished  from  myomata  by  fluctuation,  by 
separability  from  the  uterus  on  palpation,  by  more  rapid  gro^'th,  by 
the  normal  or  nearly  normal  length  of  the  uterine  cavity,  and  by  the 
absence  of  uterine  hemorrhage  or  normal  menstruation. 


Figure   172 


,^-f- 


\L^ 


Myoma  complicated  by  pregnancy.     Author's  case.     Complete  hysteromyomectomy  at  St.  Luke's 

Hospital,  Chicago;  recoverj^ 


Sactosalpinx  develops  more  rapidly,  is  situated  commonly  at  the 
side  of  the  uterus,  is  of  elongated,  ovoid  form,  is  fluctuating,  is  more 
or  less  tender  on  pressure,  does  not  cause  material  enlargement  of  the 
uterine  cavity,  and  gives  evidence  of  previous  inflammation. 

Floating  Kidney,  unless  adherent,  is  replaced  readily,  has  the  form 
of  a  kidney,  and  may  be  tender  to  pressure.  A^-ray  with  the  ureteral 
catheter  in  place  may  clear  the  diagnosis. 


TUMORS   OF   THE   UTERUS— MYOMA  371 

Prognosis  of  Myoma 

Non-operative  Prognosis.  A  inyoma  may  he  present  throu<^hout  the 
period  of  sexual  actix  ity  and  produce  no  subjective  symptoms,  or 
it  may  <:;ive  rise  to  the  symptoms  already  outlined.  It  may  partici- 
pate in  senile  atrophy  of  the  rei)r()(luctive  orj^ans  at  the  menopause  or 
in  involution  after  pregnancy,  and  thus  become  much  smaller  or  dis- 
appear. On  the  other  hand,  at  either  of  these  times  it  may  grow  larger. 
It  usually  develops  rapidly  during  gestation.  Even  small  growths, 
if  near  the  endometrium,  may  threaten  life  from  hemorrhage.  Com- 
plicating cardiac  and  renal  diseases  render  the  prognosis  more  grave. 
The  causes  of  death  include  hemorrhage,  sepsis,  peritonitis,  and  sec- 
ondary changes  in  the  tumor  itself.  Xatural  cure  may  come  from  1, 
shrinkage  and  disappearance  by  absorption — a  rare  occurrence  of 
unknown  cause;  2,  detachment  by  uterine  contraction  and  expulsion 
through  the  os  uteri  externum  and  vagina — not  very  rare;  3,  disintegra- 
tion and  gangrene — dangerous. 

The  Operative  Prognosis,  will  be  found  at  the  end  of  the  next 
chapter. 


CHAPTER  XXIV 

TUMORS  OF  THE  UTERUS— TREATMENT  OF  MYOMA 

(Continued) 

Formerly  when  the  mortality  of  radical  surgical  operations  for 
myoma  was  very  high,  numerous  and  strenuous  efforts  were  made  to 
give  relief  or  cure  by  non-surgical  measures  and  extravagant  unfounded 
claims  were  made  for  them.  Now  when  the  mortality  of  myomectomy 
and  hysteromyomectomy  in  the  hands  of  the  most  successful  operator 
is  not  more  than  1  per  cent.,  non-surgical  measures  for  the  most  part 
have  been  relegated  to  the  field  of  palliative  treatment;  perhaps  the 
most  notable  of  the  methods  now  obsolete  is  electrolysis,  a  treatment 
which  survived  chiefly  on  the  patient's  ignorance  of  its  inadequacy 
and  dangers,  upon  her  worship  of  the  mysterious,  upon  an  unreasoning 
dread  of  operative  measures,  and  upon  a  desire  to  grasp  any  other 
promising  means  of  relief. 

Strong  claims  by  observers  of  deservedly  good  reputation,  recently 
have  been  made  for  the  x-ray  as  a  means  of  symptomatic  and  ana- 
tomical cure.  Here  perhaps  the  history  of  electrolysis  may  be 
repeated : 

"  Be  not  the  first  by  whom  the  new  is  tried 
Nor  yet  the  last  to  lay  the  old  aside." 

The  treatment  of  uterine  myoma  is: 

1.  Non-surgical. 

2.  Surgical. 

1.    NON-SURGICAL   TREATMENT 

Non-surgical  measures  to  a  limited  degree  are  applicable  in  the 
treatment  of  pressure  symptoms  and  uterine  hemorrhage. 

The  Treatment  of  Pressure  Symptoms 

When  a  myoma  becomes  incarcerated  in  the  true  pelvis  under  the 
sacral  promontory  and  causes  pressure  symptoms,  the  indication  is 
to  force  it  by  manipulation  up  into  the  abdomen.  The  manipulation 
is  carried  out  best  with  the  patient  in  the  knee-breast  position,  the 
assumption  of  which  sometimes  will  cause  the  tumor  to  fall  out  of  the 
pelvis  by  force  of  gravity  alone.  In  other  cases  considerable  pressure, 
with  or  without  ansesthesia,  may  be  required  to  dislodge  it.  The  tumor, 
if  small  and  very  movable,  may  fall  back  readily  into  the  pelvis  minor, 
causing  great  mechanical  disturbance  and  necessitating  daily  replace- 
(372) 


TUMORS   OF   THE    VTERl'S  —  T HEAT M EST  OF    MYOMA        .373 

ineiit.  If  tlu'  tuiiKir  t'roiii  iiiiy  cause,  such,  tor  cxauiplc,  as  adhesions, 
cannot  he  forced  up  into  the  ahdonien  and  pressure-synijjtonis  are 
urgent   it   will   ha\e  to  be  renio\ed. 


The  Treatment  of  Uterine  Hemorrhage 

Medication.  —  Iron,  Arsenic,  and  the  li titer  Tunics  are  useful  in 
the  treatment  of  the  aniemia  which  commonly  results  from  uterine 
hemorrhage;  such  measures,  however,  are  subordinate  to  the  more 
direct  treatment  to  be  t)utlined  in  the  following-  paragraphs.  Ergot 
stands  at  the  head  of  the  numerous  drugs  that  have  been  used  in  the 
treatment  of  uterine  myoma,  because  of  its  power  to  produce  uterine 
contractions  and  consequently  to  control  hemorrhage  and  thereby  to 
preserve  the  vitality  of  the  patient  until  relief  may  come  with  the 
menopause  or  after  surgical  removal  of  the  tumor.  The  drug,  if  long 
continued,  is  not  well  borne  by  the  stomach ;  hence,  it  should  be  given 
either  by  hypodermic  injection  or  by  rectal  suppositories.  The  dose  is 
determined  by  the  effect.  If  used  at  all,  sufficient  should  be  given  to 
control  bleeding,  ergot  may  be  supplemented  by  the  ice-bag  over  the 
hypogastrium.  Ilydrastin  and  calcium  chloride  also  have  some  value 
in  the  control  of  uterine  hemorrhage.  For  the  same  purpose  styjjticin 
in  one  or  two  grain  doses,  either  alone  or  combined  with  ergotin  and 
suprarenal  extract  may  be  given  advantageously  in  capsules  four  to  six 
times  a  day. 

Intra-uterine  Tamponade. — When  hemorrhage  is  profuse  and  exhaust- 
ing, the  most  effective  means  of  temporary  hsemostasis  is  intra-uterine 
tamponade  made  through  a  Sims'  or  Simon's  speculum.  A  continuous 
strip  of  antiseptic  gauze  should  be  packed  tightly  into  the  uterus, 
especially  into  the  cervical  cavity,  and  renewed  every  forty-eight  hours 
mitil  the  flow^  has  ceased.  In  this  way  an  exhausted  exsanguinated 
patient  may  in  a  few  weeks  regain  strength  to  endure  the  radical  opera- 
tion. This  treatment  in  the  hands  of  the  author  in  one  case  has  been 
followed  not  only  by  relief  of  menorrhagia,  but  also  by  almost  total 
disappearance  of  the  tumor.  The  tampon  was  used  during  three  con- 
secutive menstruations,  and  the  tumor  was  reduced  from  the  size  of  a 
child's  head  to  that  of  a  hen's  egg.  The  age  of  the  patient,  forty-five 
years,  and  the  near  approach  of  the  menopause  may  account,  partially 
at  least,  for  this  extraordinary  sequence. 

Intra-uterine  Styptics. — Churchill's  tincture  of  iodine,  the  10  per 
cent,  solution  of  antipyrine,  and  other  styptics  may  be  injected  very 
sparingly  into  the  uterus  for  the  control  of  hemorrhage.  Iron  persul- 
phate, sometimes  used,  is  apt  to  form  hard  blood-clots  which  are  not 
easily  expelled  nor  removed,  and  which  therefore  may  become  septic 
and  dangerous.  Intra-uterine  styptics,  generally  speaking,  are  inferior 
to  tamponade,  but  may  be  combined  with  it. 

Infusion  of  Normal  Salt  Solution  by  hypodermoclysis  or  by  infusion  of 
it  directly  into  the  vein  or  the  introduction  of  it  into  the  rectum  by  the  drop 


374  TUMORS,    TUBAL   PREGNANCY,    MALFORMATIONS 

method  is  described  in  the  chapter  on  the  After-treatment  of  j\lajor 
Operations.  Salt  solution  alone  is  inadequate  to  the  saving  of  many 
patients  who  otherwise  would  die  from  loss  of  blood.  Clinically  it  is  of 
use  in  the  less  dangerous  hemorrhages  and  in  graver  cases  may  be  used 
to  advantage  until  preparation  for  transfusion  of  human  blood  can  be 
made. 

Injection  of  Beef  Blood  Serum. — Beef  blood  serum  freshly  obtained 
from  the  slaughter  house  may  be  defibrinated  and  a  quart  of  the 
resultant  serum  containing  in  solution  1  per  cent,  sodium  bicarbonate 
may  be  advantageously  injected  into  the  rectum  in  divided  doses 
every  twenty-four  hours.  The  effect  of  this  treatment  sometimes  is 
marvellous.  I  have  observed  haemoglobin  to  be  increased  from  twenty- 
five  to  fifty,  and  the  red  blood  corpuscles  to  be  increased  from  two  to 
three  and  a  half  millions  under  two  weeks  of  this  treatment,  which  is 
strongly  recommended  preparatory  to  a  radical  operation  in  cases  in 
which  anaemia  is  so  extreme  as  to  prohibit  an  immediate  radical  opera- 
tion. In  such  a  case  it  would  be  unwise  ordinarily  to  proceed  to 
operative  measures  with  the  haemoglobin  much  under  sixty  or  the 
red  blood  count  less  than  three  millions  to  the  cubic  millimeter. 

Subcutaneous  Injection  of  Human  Blood. — Whole  blood  or  blood  serum 
may  be  injected  hypodermically,  the  former  must  be  taken  from  the 
donor  directly  into  a  vaseline-coated  syringe  to  prevent  clotting  and 
injected  into  the  tissues  of  the  patient;  the  latter  in  amounts  of  at  least 
four  drachms  may  be  injected  repeatedly,  the  serum  having  been  sep- 
arated by  aseptic  technique  from  the  blood  of  a  healthy  donor;  these 
methods  are  inferior  to  direct  blood  transfusion,  but  are  permissible 
when  the  transfusion  apparatus  or  the  skill  to  use  it  are  not  at  hand. 

Transfusion  of  Human  Blood  is  known  to  replace  physiologically 
blood  that  has  been  lost  and  to  resuscitate  patients  who  otherwise 
would  die  from  hemorrhage;  it  is  reserved  for  two  classes  of  cases: 
1,  those  who  have  bled  so  profusely  that  life  is  in  danger;  2,  very 
anaemic  patients  who  for  some  special  reason,  such  as  gangrene  of  the 
tumor  or  twisted  pedicle,  cannot  wait  for  more  deliberate  preparatory 
£reatment  but  demand  immediate  operation.  Arthur  H.  Curtis  has 
developed  an  especially  safe  and  efficient  method  of  direct  blood  trans- 
fusion, an  account  of  which  will  be  found  in  the  chapter  on  Uterine 
Hemorrhage. 

SURGICAL    TREATMENT 

It  would  be  unprofitable  to  enlarge  upon  a  great  variety  of  pro- 
cedures which  have  become  or  seem  destined  to  become  obsolete. 
The  more  useful  operations  for  the  treatment  of  fibromyomata  of  the 
uterus  will  be  divided  as  follows: 

1.  Palliative  operations. 

2.  Radical  vaginal  operations. 

3.  Radical  abdominal  operations. 


Ti'MOl^S   OF    Till-:    rTn/i'rs—Tli'FATMKXT  OF    M)(J.\IA        375 

1 .  Palliative  Operations 

The  cliict'  palliative  operation  of  recognized  value  is  curettage. 

Curettage.— If  the  tumor  by  its  irritating  presence  gives  rise  to 
hemorrhagic  endometritis,  curettage  is  indicated  i)recisely  as  it  would 
be  in  hemorrhagic  endometritis  from  any  other  cause.  Generally  the 
operation  is  followed  by  some  relief  from  the  menorrhagia,  but  is 
seldom  permanent  in  its  results,  and  usually,  therefore,  must  be 
repeated  again  and  again.  It  is  especially  useful,  in  connection 
with  intra-uterine  gauze  tamponade,  to  control  hemorrhage  until  an 
exhausted  patient  can  gain  })lood  and  strength  for  a  more  radical 
operation,  or,  in  cases  of  small  tumors,  until  the  menopause  has 
passed.     The  technique  of  curettage  is  described   in  Chapter  Y. 

2.  Radical  Vaginal  Operations 

The  vaginal  route  is  preferable  when  the  tumor  can  be  reached  readily 
in  that  way.  All  cervical  fibroids,  all  intra-uterine  pedunculated  fibroids 
not  too  large  may  well  be  removed  by  the  vagina.  There  are  two  rather 
pertinent  objections  to  the  removal  of  a  large  myoma  by  the  vagina: 
1 .  The  possible  presence  of  other  smaller  tumors  which  may  be  over- 
looked in  the  original  diagnosis,  and  which  cannot  be  taken  care  of 
by  the  vaginal  operation.  2.  The  possible  presence  of  unrecognized 
or  unrecognizable  pus-tubes  or  ovarian  abscesses.  ^lany  times  an 
unsuspected  accumulation  of  pus  has  been  ruptured  with  disastrous 
results  in  the  enucleation  or  morcellation  of  a  myoma  through  the  vagina. 
The  radical  vaginal  operations  are:  A,  torsion  for  small  pedunculated 
intra-uterine  myomata;  B,  vaginal  hysterectomy;  C,  vaginal  enuclea- 
tion and  morcellation. 

A.  Torsion  for  Small  Pedunculated  Myomata. — When  the  uterus  is 
dilated,  either  by  uterine  contraction  on  the  tumor  or  by  instrumental 
means,  the  pedunculated  tumor  is  seized  by  vulsellum  forceps,  drawn 
down,  and  twisted  off  or  removed  by  the  scissors.  The  uterus  then  is 
packed  with  aseptic  gauze.  In  the  removal  of  a  pedunculated  myoma 
traction  on  the  growth  should  not  be  very  strong,  for  the  uterine  wall 
may  be  drawn  down  and  accidentally  cut  through  in  the  removal  of 
the  growth.    Fatal  peritonitis  has  resulted  from  this  accident. 

B.  Vaginal  Hysterectomy. — ^Yhen  numerous  small  tumors  are  scat- 
tered throughout  the  uterus.  Figure  173,  and  the  number  is  so  large 
that  individual  enucleation  is  impossible,  and  when,  moreover,  the 
mass  is  not  too  large  to  be  delivered  through  the  vagina,  it  may  be 
removed  entire  by  vaginal  hysterectomy.  Delivery  through  the  vagina 
sometimes  presents  unexpected  difficulties.  Preparation  should  be 
made  therefore  for  supplemental  abdominal  section. 

C.  Vaginal  Enucleation  and  Morcellation. — Intramural  myomata,  espe- 
cially if  situated  in  the  lower  segments  of  the  corpus  or  in  the  cervix 
uteri  and  not  too  large,  may  be  enucleated  safely  and  removed  through 
the   vagina    by   traction    and   morcellation.      The   operation    though 


376 


TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


generally  supposed  to  be  of  more  recent  origin  and  accredited  to  French 
surgeons,  has  been  advocated  and  practised  consistently  by  Thomas 
Addis  Emmet  for  at  least  forty  years.     It  is  applicable  to  cases  in 


Figure  173 


Radical  vaginal  operation.      Morcellation  of  an  intra-uterine  myoma.     Emmet's  method. 


which  the  tumor  is  accessible  through  the  vagina  but  too  large  to  be 
enucleated  and  delivered  entire.  The  presenting  part  of  the  tumor  is 
repeatedly  seized  with  heavy  vulsellum  forceps,  making  traction  with 


TCMORS  OF   Tin-    VTERUS— TREATMENT  OF  MYOMA        377 

one  forceps  after  another  and  eiittins;-  a\va\-  one  pieee  after  another  with 
scissors,  until  the  whole  tumor  has  been  removed.  As  pieee  after  piece 
is  cut  away  contraction  of  the  uterus  forces  down  other  portions  of  the 
tumor  and  renders  them  accessible  to  more  tractions  and  more  excisions. 


FlGTRE    174 


Figure  17.5 


Figure  174. — Radical  vaginal  operation.  Author's  incision.  Lines  indicating  the  vaginal  inci- 
sions to  expose  the  anterior  uterine  wall  preparatory  to  di%'-iding  it  with  scissors. 

FiGtTRE  17.5. — Author's  incision,  flaking  longitudinal  di\ision  of  anterior  wall  of  uterus,  in  order 
to  e.xpose  the  field  of  operation  for  the  removal  of  a  myoma. 

The  tumor  may  be  rendered  more  accessible  by  incision  of  the  cervix 
uteri  even  to  the  internal  os,  and  an  intramural  tumor  may  require 
division  of  the  mucosa  and  subjacent  muscular  tissue  before  beginning 
enucleation. 

The  author's  method  of  anterior  incision  of  the  cenix  which  gives 
the  minimum  of  traumatism  and  the  maximum  of  accessibility  to  the 
endometrium,  is  performed  as  follows:^ 


'  Published  by  the  author  in  the  Transactions  of  the  Minnesota  State  Medical  Society.  1896,  and 
republished  in  the  .Journal  of  the  American  Medical  Association,  August  15,  1896. 


378  TUMORS,    TUBAL   PREGNANCY,    MALFORMATIONS 

1.  Make  a  circular  incision  in  front  of  the  uterus  which  shall  separate 
the  vaginal  wall  from  the  cervix  at  the  uterovaginal  attachment,  as 
shown  in  Figures  174  and  175. 

2.  Incise  the  anterior  vaginal  wall  from  the  middle  point  of  the 
first  incision  for  a  distance  of  about  one  inch,  taking  care  not  to  invade 
the  bladder  and  to  avoid  the  ureter  on  either  side. 

3.  Separate  the  bladder  from  the  uterus  by  means  of  the  finger 
covered  wdth  gauze  or  with  some  blunt  instrument,  keeping  close  to  the 
uterus  until  the  peritoneum  is  reached,  but  not  divided.  Then  expose 
with  retractors  or  fingers  the  anterior  wall  of  the  uterus. 

4.  Divide  the  anterior  wall  of  the  uterus  longitudinally  in  the  median 
line  by  means  of  scissors  to  whatever  extent  may  be  necessary  to  render 
the  tumor  accessible.  If  necessary,  the  peritoneum  may  be  opened 
and  the  incision  carried  up  into  the  corpus  uteri. 

This  simple  anterior  incision  permits  wide  separation  of  the  lateral 
fragments  of  the  anterior  uterine  wall,  and  thereby  exposes  the  endo- 
metrium for  examination  or  operation,  and  may  render  accessible  a 
myoma  in  any  part  of  the  uterus.  It  has  the  following  advantages 
over  lateral  incisions :  1 .  There  is  less  traumatism — one  incision  instead 
of  two.  2.  The  parametria  are  not  opened  and  exposed  to  possible 
sepsis.  3.  The  tumor  is  more  accessible  because  the  anterior  uterine 
wall  is  out  of  the  way  instead  of  being  between  the  operator  and  the 
field  of  operation.  4.  A  much  longer  incision  may  be  made,  if  necessary, 
because  the  broad  ligaments  are  not  involved.  5.  There  is  less  hemor- 
rhage. 6.  The  pelvic  cavity  may  be  reached  easily  through  this  incision 
for  any  further  operation  on  the  uterine  appendages  or  peritoneum. 
Even  a  small  pedunculated  subperitoneal  tumor  may  be  removed 
through  this  incision.  An  imperative  measure,  preliminary  to  these 
operations,  is  scrupulous  disinfection  of  the  vagina  and  the  external 
genitals.  After  the  usual  cleansing  of  the  vagina,  as  described  in 
Chapter  II.,  the  vagina  should  be  packed  lightly,  but  in  all  its  parts, 
with  gauze  saturated  with  a  70  per  cent,  alcohol.  This  is  most  essential 
as  an  aseptic  measure,  especially  in  view  of  the  possibility  that  an  open- 
ing for  drainage  may  have  to  be  made  from  the  pelvic  cavity  into  the 
vagina. 

3.  Radical  Abdominal  Operations 

Radical  abdominal  operations  are  adapted  to  large  tumors  which 
cannot  be  removed  well  through  the  vagina.     They  are: 

1.  Myomectomy — removal  of  the  tumor  without  sacrificing  any  part 
of  the  uterus. 

2.  Supravaginal  hysteromyomectomy — removal  of  the  tumor  together 
with  the  corpus  uteri  and  the  supravaginal  portion  of  the  cervix  uteri. 

3.  Complete  hysteromyomectomy — removal  of  the  tumor  and  the  entire 
uterus. 

1.  Abdominal  Myomectomy. — Abdominal  myomectomy — removal  of 
the  tumor  without  sacrificing  any  part  of  the  uterus — is  indicated  for 
the  tumors  mentioned  below  under  a,  h,  and  c. 


TUMORS  OF   Till']    UTERUS— TREATMENT  OF  MYOMA        '.u\) 

a.  I'l'dunculated  subperitoneal  tumors.    Figure  176. 

b.  Small  iiitrauiural  and  subserous  tumors,  when  the  growths  ean 
be  removed  with  sHiilit  traumatism  and  the  uterine  wound  closed  with 
interrupted  or  continuous  cat<i;ut  sutures.  Figures  177  and  178.  An 
improvement  on  the  interrupted  and  continuous  sutures  is  the  purse- 
string  suture  shown  in  Figures  179  to  182,  which  has  the  following 
advantages:  1,  ra])idity  of  application;  2,  ready  and  reliable  ha'mo- 
stasis;  o,  slight  traumatism. 


FiGUKK    176 


w 


Mj'omectomy.     Pedunculated  myoma  rernovcl;   wound  Iseing  closed  by  continuous  catgut  suture. 

c.  Some  large  intramural  and  subserous  tumors  which  can  readily 
be  enucleated — shelled  out — and  the  uterine  wounds  closed  w^ith  or 
without  drain.    Figures  183  and  184. 

The  growths  indicated  under  a  and  b  may  be  treated  easily  and 
safely  by  enucleation  and  suture. 


380 


TUMORS,    TUBAL   PREGNANCY,    MALFORMATIONS 


The  larger  growths  indicated  under  c,  even  though  lying  deep  in 
the  uterine  wall  or  broad  ligament,  in  many  cases  may  be  "shelled 
out"  with  the  greatest  ease,  and  the  tumor-cavities  from  which  they 
have  been  remove(i  may  be  closed  successfully  and  obliterated  by 
buried  sutures.  While  a  large  growth  is  being  enucleated  and  the 
uterine  wound  closed,  hemorrhage  may  be  controlled  by  a  temporary 
ligature  of  rubber  tubing  placed  around  the  lower  segment  of  the  uterus. 
Before  closing  the  abdominal  wound  this  ligature  is  removed,  and  a  little 
time  is  allowed  to  make  sure  that  there  is  to  be  no  hemorrhage  from 
the  uterine  wound,  this  ligature  usually  is  not  needed.  Hemorrhage 
usually  is  controlled  in  great  measure  by  the  uterine  contraction 
which  follows  enucleation.  The  mortality  of  this  method,  even  for 
rather  larger  tumors,  is  surprisingly  small. 


Figure  177 


Myomectomy.  Uterus  with  eight  myomata  to  be  removed  and  one  being  removed.  The  number 
of  myomata  here  shown  is  larger  than  should  ordinarily  be  removed  by  this  method.  Unless  they  are  very 
small  and  subperitoneal,  hysterectomy  uwuld  be  safer. 

In  case  of  a  very  large  intramural  tumor,  and  very  extensive  traumatism 
w4th  enormous  surfaces  to  be  united  by  buried  sutures,  the  method  of 
abdominal  myomectomy  as  above  described  involves  great  danger 
of  sepsis  and  secondary  hemorrhage,  and  should  give  place  usually  to 
hysteromyomectomy  or  be  modified  by  the  introduction  of  drainage 
as  follows: 

Drainage  in  Abdominal  Myomectomy. — After  the  tumor  has  been 
enucleated  an  opening  is  made  from  the  tumor  cavity  to  the  uterine 
cavity.  If  the  uterine  canal  is  patulous,  a  continuous  strip  of  gauze 
is  carried  from  the  tumor-cavity  directly  through  into  the  vagina, 
the  tumor-cavity  being  packed  with  the  same  continuous  strip.  The 
uterine  w^ound  then  is  closed  with  deep  catgut  sutures,  the  peritoneal 
margins  being  turned  in  and  united,  as  shown  in  Figure  183,  so  that 


TUMORS  OF   THE   UTERUS— TREATMENT  OF  MYO^fA        381 

Figure  17S 


Myomectomy;  usual  method  of  suture.     Same  uterus  as  shown  in  Figure  177.     Shows  method  of 
closing  wounds  made  by  removal  of  myomata;  continuous  catgut  sutures. 


Figure  179 


Figure  180J 


Figure  ISl 


Figure  182 


Figure  179. — Author's  operation,  first  step.  Purse-string  ligature  in  place  around  the  myoma 
which  is  to  be  removed. 

Figure  180. — Second  step.     Capsule  split  and  myoma  exposed. 

Figure   181. — Third  step.     Enucleation  of  myoma. 

Figure  182. — Final  step.  Fundus  uteri.  One  m^oma  has  been  removed,  and  wound  closed  by 
tying  purse-string  ligature.  Another  myoma  has  been  removed,  and  purse-string  ligature  is  being 
tied. 

24 


382 


TUMORS,    TUBAL   PREGNANCY,    MALFORMATIONS 


the  whole  uterine  traumatism,  now  isolated  from  the  peritoneum,  may 
be  drained  adequately  through  the  vagina.  If  the  uterine  canal  is  not 
sufficiently  patulous  to  admit  the  gauze,  it  may  be  dilated  or  the  walls 
of  it  may  be  incised  anteriorly  and  posteriorly  by  means  of  a  herniotomy- 
knife,  or  it  may  be  both  dilated  and  incised.  The  vagina  is  filled  loosel\' 
with  gauze  to  meet  that  which  protrudes  from  the  uterus,  and  the 
vulva  is  covered  by  a  gauze  pad,  to  be  changed  as  often  as  it  becomes 
moist.  The  gauze  should  be  removed  in  two  or  three  days.  Care  is 
necessary  in  the  closure  of  the  uterine  wound  that  the  gauze  be  not 
caught  in  a  suture,  because  then  removal  would  have  to  be  postponed 
until  after  absorption  of  the  suture.  In  cases  in  which  there  is  no  fear 
of  hemorrhage  and  the  uterine  canal  is  patulous,  or  can  be  made  so 
by  dilatation,  incision  into  the  endometrium  alone  may  be  sufiicient 
for  drainage,  i.  e.,  the  gauze  may  be  omitted. 

Figure  183 


Myomectomy.  An  intramural  myoma  has  been  enucleated;  an  opening  has  been  made  between 
the  tumor  cavity  and  the  endometrium;  uterovaginal  gauze  drain;  uterine  wound  closed  by  suture. 
The  opening  in  the  uterine  wall  is  intended  to  show  the  gauze. 


An  intraligamentous  myoma  may  be  shelled  out  readily  from  its 
bed  between  the  folds  of  the  broad  ligament.  These  same  principles 
of  drainage  apply  as  in  the  case  of  intramural  tumors,  except  as  to  the 
route  of  drainage,  which  should  be,  not  through  the  uterine  canal,  but 
through  an  opening  which  is  made  readily  from  the  tumor-cavity  to 
a  point  in  the  vagina  just  back  of  or  in  front  of  the  uterus.  In  excep- 
tional cases  it  may  be  necessary  for  purposes  of  hsemostasis  to  ligature 


TUMORS  OF   THE   UTERI  S— THE ATMENT  OF   MYOMA       383 

the  ovarian  or  utoriiie  artery,  or  both.  Experience  has  shown  that 
sloujj:hinij;  of  the  uterus  from  thus  euttinf,^  olf  tliis  l)loo(l-supi)ly  is  not 
to  be  feared.    See  Fii,nires  1S3  and  1S4. 

Intra-abdominal  closure,  with  va<,anal  drainage  of  the  tumor-cavity, 
was  suggested  early  by  August  Martin,  but  he  appears  not  to  have 
practised  the  method  extensively. 

The  author's  experience  since  1889  witli  the  al)ove  technique  shows: 
first,  almost  entire  freedt)m  from  mortality;  second,  prompt  and  un- 
eventful recovery;  third,  the  most  gratifying  permanent  results.  The 
method  is  undoubtedly  applicable  to  a  much  larger  number  of  tumors 
than  generally  is  supposed.  Removal  of  the  uterus  for  myoma  is  often 
necessary,  but  not  so  often  as  statistics  would  indicate.    In  the  majority 


FiGUHE    lS-1 


Myomectomy.   Intraligamentous  myoma  has  been  removed  from  space  between  folds  of  broad  ligament. 
Gauze  drain  from  this  space  through  an  opening,  made  for  the  purpose,  direct  into  the  vagina. 

of  cases  the  uterine  appendages  will  be  found  normal,  and  in  a  large 
proportion  of  this  majority  the  tumor  may  be  enucleated  and  the  wound 
successfully  closed,  precisely  as  would  be  done  for  the  removal  of  such 
a  tumor  in  any  other  part  of  the  body.  Cases  of  very  large  tumors,  and 
cases  in  which  many  small  tumors  are  scattered  through  the  uterine 
wall,  will  require  hysterectomy;  but  the  conservative  operation  of  sim- 
ple enucleation  often  will  be  indicated  when  the  tumor  is  even  larger 
than  the  foetal  head,  and  in  cases  of  multiple  myomata  when  there  are 
not  too  many  tumors.  The  preservation  of  a  non-infected  uterus, 
even  when  the  appendages  have  to  be  removed,  is  desirable. 

Drainage  of  the  tumor-cavity  by  stitching  it  into  the  abdominal 
wound  and  packing  it  with  gauze  has  been  carried  out  successfully  in 
many  cases.  The  vaginal  route  for  drainage,  however,  ofl'ers  decided 
advantages,  and  therefore  usually  will  be  preferred.^ 

•  The  author  used  uterovaginal  drainage  in  myomectomy  in  April  1SS9;  his  first  case  was  reported 
in  the  American  Journal  of  Obstetrics,  September,  1S89. 


384  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

2.  Supravaginal  Hysteromyomectomy. — Supravaginal  hysteromyo- 
mectomy  is  removal  of  the  tumor,  the  corpus  uteri,  and  the  supra- 
vaginal portion  of  the  cervix,  through  an  abdominal  incision,  leaving 
no  part  of  the  uterus  except  the  vaginal  portion  of  the  cervix. 

Technique  of  Supravaginal  Hysteromyomectomy. —  The  usual  oijeration 
is  to  secure  the  ovarian  and  uterine  arteries  by  means  of  strong 
catgut  ligatures,  and  after  removal  of  the  tumor,  corpus  uteri,  and 
supravaginal  portion  of  the  cervix,  to  close  the  uterine  stump  by 
means  of  a  continuous  suture  running  from  side  to  side,  and  then  to 
close  the  wound  in  the  broad  ligaments  by  means  of  another  continu- 
ous suture  also  running  in  the  same  direction.  See  Figure  185.  This 
method  is  open  to  the  following  objections:  1.  The  severed  broad  liga- 
ments retract  to  the  sides  of  the  pelvis,  where  they  can  no  longer  give 
adequate  support  to  the  bladder,  vagina,  and  rectum;  the  frequent 
consequence  is  exaggerated  descent  of  the  pelvic  floor  with  disabling 
and  permanent  cystocele  and  rectocele.  2.  The  rectum  and  bladder 
are  brought  into  close  relations  with  only  a  thin  wall  between,  so 
that  the  possibility  of  infection  from  one  to  the  other  is  increased. 
3.  In  many  cases  the  bladder  is  drawn  over  the  uterine  stump  in 
order  to  cover  it;  this  may  give  rise  to  mechanical  irritation  of  the 
bladder. 

The  author  has  attempted  to  overcome  the  difficulties  above  men- 
tioned by  end-to-end  approximation  of  the  broad  ligaments.  Figures 
186  to  194.  The  preliminary  disinfection  of  the  external  genitals,  vagina, 
and  uterus  having  been  made  the  steps  of  supravaginal  hysteromyo- 
mectomy are  as  follows: 

A.  Abdominal  incision. 

B.  Delivery  of  the  tumor  through  the  abdominal  wound. 

C.  Ligature  of  the  ovarian  and  uterine  arteries,  and  removal  of 

the  tumor  together  with  the  corpus  uteri  and  supravaginal 

portion  of  the  cervix  uteri. 
I).  Toilet  of  the  peritoneum. 
E.  Closure  of  the  abdominal  wound. 

A.  In  case  of  a  large  tumor  the  abdominal  incision  should  be  made 
nearer  the  umbilicus  than  the  pubes,  to  avoid  the  bladder,  which 
by  the  growth  of  the  tumor  not  infrequently  is  drawn  up  out  of  the 
pelvis.  The  incision,  first  exploratory — that  is,  large  enough  to  admit 
one  or  two  fingers — may  be  enlarged  sufficiently  to  permit  delivery  of 
the  tumor. 

B.  Delivery  of  the  tumor  through  the  abdominal  wound  is  effected 
sometimes  by  pressure  on  the  abdominal  walls  around  the  incision, 
so  as  to  squeeze  it  out.  Usually  it  is  delivered  by  traction  with 
the  hands  or  with  heavy  vulsellum  forceps.  In  some  cases  the  tumor 
is  fixed  so  firmly  in  the  pelvis  that  it  cannot  be  brought  through  the 
abdominal  wound  until  after  some  of  the  pressure-forceps  or  ligatures 
have  been  placed  around  the  arteries  and  the  mass  partially  severed 
from  the  broad  ligaments.  If  the  abdominal  incision  has  been  very  long, 
and  the  intestines  are  much  inclined  to  protrude  through  the  wound, 


Tl'MURS   OF   T[IE   IT ERl'S— TREATMENT  OF   MYOMA        .'^85 

tlu'\'  may,  as  soon  as  tlic  tumor  has  been  brought  tlir(ju;,Mi,  be  held 
l)a('k  by  a  large  flat  gauze  pad  or  b\-  suture  of  the  upper  part  of  the 
wound.  It  is  clearly  important  to  prevent  protrusion  of  the  intestine, 
and  thereby  to  lessen  exposure  of  the  peritoneum. 

C.  In  a  majority  of  all  eases  the  operation  may  be  facilitated  by  the 
use  of  long-bladed  forceps  to  secure  temporary  htemostasis  of  the  uterine 
and  ovarian  arteries  during  removal  of  the  mass,  and  to  be  substituted 
by  ligatures  as  soon  as  the  mass  has  been  removed.  See  Figures  186 
to  190.  This  use  of  forceps  will  enable  the  operator  to  get  the  tumor 
rapidly  out  of  the  way,  and  to  complete  the  operation  with  great 
speed,  and  to  avoid  hemorrhage.  The  further  steps  of  this  part  of  the 
operation  are  as  follows: 

1.  Clamp  the  arteries  as  shown  in  the  diagrams;  the  outer  forceps 
shut  oti"  the  ovarian  artery  as  it  passes  inward  through  the  broad  liga- 
ment toward  the  uterus;  the  inner  forceps  prevent  reflex  hemorrhage 
from  the  iitero-ovarian  anastomosis  at  the  uterine  end  of  the  broad 
ligament. 

2.  Divide  the  broad  ligaments  by  means  of  scissors. 

3.  Divide  the  peritoneal  investment  of  the  uterus  in  front  of  the 
cervix  just  above  the  bladder  attachment;  this  is  done  best  by  lightly 
cutting  the  peritoneum  at  the  vesico-uterine  reflexion  with  pointed 
scissors. 

4.  Strip  the  bladder  peritoneum  together  wdth  the  attached  bladder 
away  from  the  cervix  down  toward  the  vagina  to  the  region  of  the 
uterine  arteries.  During  the  stripping  off  of  the  bladder  the  relations 
of  it  may  be  recognized  by  a  sound  in  the  bladder.  The  stripping 
is  accomplished  best  by  means  of  gauze  sponge  pressure. 

5.  Clamp  the  uterine  arteries  by  means  of  forceps;  in  applying  the 
clamps,  care  is  necessary  to  avoid  the  ureters,  which  sometimes  rim 
very  close  to  the  uterus.  Some  operators  take  the  precaution  to  have 
a  catheter  in  each  ureter  in  order  to  keep  track  of  it  during  the 
operation. 

6.  Remove  the  tumor  and  all  the  uterus  except  the  vaginal  por- 
tion by  means  of  a  wedge-shaped  incision  so  directed  that  the  uterine 
stump  may  be  sutured  in  a  line  running  from  before  backward,  not 
from  side  to  side.  Cauterization  of  the  remaining  portion  of  the  cer- 
vical canal  with  95  per  cent,  carbolic  acid,  here  is  most  important;  this 
may  be  applied  on  a  probe  or  grooved  director.  Sponges  and  instru- 
ments used  in  connection  with  the  cervical  canal  should  for  reasons  of 
asepsis  not  be  used  elsewhere. 

7.  Place  permanent  ligatures  on  the  ovarian  and  uterine  arteries 
and  remove  the  pressure-forceps.  It  is  important  that  the  forceps  be 
loosened  by  an  assistant  while  the  ligatures  are  being  drawn  tight, 
because  if  tied  before  the  forceps  are  removed,  dangerous  hemorrhage 
may  result.  The  uterine  arteries  are  located  sometimes  by  sight, 
sometimes  by  touch,  and  accordingly  are  secured  by  ligature,  isolated 
or  en  masse.  The  ovarian  artery  usually  is  tied  en  masse.  In  tying 
either  the  ovarian  or  uterine  arteries  en  masse,  it  is  of  great  importance 


386  TUMORS,    TUBAL  PREGNANCY,    MALFORMATIONS 

to  place  the  ligatures  so  that  the  ligatured  part  ivill  not  be  deprived  ivholly 
of  circulation — that  is,  so  that  it  will  receive  collateral  circulation — arid 
therefore  not  he  subject  to  necrotic  processes.  The  following  figures  show 
the  ligatures,  which  have  been  applied  in  such  a  manner  as  not  to  produce 
necrosis  of  the  stump. 

In  some  cases  the  tumor  so  fills  the  pelvis  that  the  forceps,  for  lack 
of  room,  cannot  be  applied.  Then,  an  elastic  ligature  having  been 
thrown  rapidly  around  the  cervix  for  temporary  hsemostasis,  the  tumor 
may  be  enucleated  and  the  size  of  the  mass  so  reduced  that  the  forceps 
may  be  applied.  As  the  incision  is  carried  down  through  the  broad 
ligament  on  each  side,  additional  forceps,  if  needed  to  control  hemor- 
rhage, may  be  used  until  the  entire  mass — tumor,  corpus  uteri,  and 
supravaginal  portion  of  the  cervix — has  been  removed;  then  perma- 
nent ligatures  on  the  ovarian  and  uterine  arteries  should  be  substituted 
for  the  forceps. 

In  this  operation  the  uterine  appendages,  if  normal,  should  be  con- 
served. 

D.  Toilet  of  the  peritoneum,  which  consists  of  the  following  steps: 

1.  Ligature  of  any  bleeding  points. 

2.  If  the  case  is  simple  and  requires  no  vaginal  drain,  the  broad 
ligaments  should  be  closed  by  end-to-end  approximation,  as  described 
in  the  following  figures.  If  there  is  fear  of  possible  sepsis  in  connection 
with  the  vaginal  wound,  or  other  reason  to  use  vaginal  drainage,  the 
walls  of  the  remaining  portion  of  the  cervix  should  be  split,  as  shown 
in  Figure  192,  and  a  continuous  strip  of  sterile  gauze  should  be  passed 
from  the  pelvic  cavity  between  the  fragments  of  the  cervix  into  the 
vagina,  as  shown  in  Figure  193.  This  strip  should  fill  the  vagina 
loosely  and  present  at  the  vulva,  and  should  be  removed  about  two 
days  after  the  operation,  and  the  removal  of  it  should  be  followed 
by  gentle  low  pressure,  vaginal  douches,  0.5  per  cent,  lysol  in 
sterile  water.  The  vaginal  w^ound  should  be  closed  as  indicated  in 
Figures  193  and  194. 

E.  The  abdominal  wound  should  be  closed  without  drain  in  the 
usual  manner,  as  described  in  Chapter  VI. 

3.  Complete  Abdominal  Hysteromyomectomy. — The  removal  of  the 
entire  myomatous  uterus  is  indicated:  first,  when  the  uterus  is  septic 
or  otherwise  so  diseased  as  to  render  the  presence  of  any  part  of  it 
unsafe;  second,  when  on  account  of  extensive  traumatism  or  suppura- 
tion vaginal  drainage  is  required.  In  addition  to  the  above  indications 
there  is  a  certain  legitimate  latitude  of  choice,  so  that  the  bias  of  the 
operator  properly  may  be  in  the  direction  of  complete  hysterectomy. 
The  operation  demands  the  same  antiseptic  preparation  as  already 
laid  down  for  supravaginal  hysteromyomectomy. 

Technique  of  Complete  Abdominal  Hysteromyomectomy. — The  abdomi- 
nal incision;  the  delivery  of  the  tumor;  the  clamping  and  ligature 
of  the  arteries;  the  division  of  the  broad  ligaments;  and  the  closure 
of  the  wounds,  both  pelvic  and  abdominal,  are  substantially  the  same 
as  already  described  for  supravaginal  hysteromyomectomy. 


FlODRE    185' 


Supravaginal  Hysteromyomectomy.  Ordinary  faulty  method  of  closing  broad  ligaments. 
The  ovarian  and  uterine  arteries  have  been  secured  by  means  of  strong  catgut  ligatures,  the 
uterine  stump  has  been  closed  by  a  continuous  suture  running  from  side  to  side,  and  the  wound 
in  the  broad  ligaments  is  being  whipped  together  by  a  continuous  catgut  suture.  The  liga- 
tures on  the  uterine  arteries  are  covered  in  by  peritoneum,  those  on  the  ovarian  arteries  are 
not  so  covered. 

A  better  method  of  securing  the  broad  ligaments  by  end-to-end  appro.ximation  is  described 
in  the  following  figures,  186  to  196. 


'  This  .series  of  illustration.?,  Figures  18.5  to  196,  with  text,  were  published  by  the  author 
in  the  .Journal  of  the  American  Medical  Association,  December,  1906.  \  similar  series  also 
wa.s  published  in  the  same  journal,  March  29,  1902. 

387 


Figure  186 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  Median  incision.  Abdominal  wound 
held  apart  by  retractor.  Myomatous  uterus  delivered  through  the  wound.  Broad  ligament 
on  either  side  clamped  by  two  long  forceps  preparatory  to  supravaginal  amputation  of  the 
uterus.     Cervix  uteri  between  the  tips  of  forceps.     Bladder  in  front. 


388 


Figure  187 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  A  transverse  incision  has  been  made 
in  front  of  the  eerx-ix  uteri  at  the  vesical  reflexion,  each  end  terminating  where  the  broad 
ligament  joins  the  uterus.  A  similar  incision  has  been  made  through  the  peritoneum  on  the 
posterior  waU  of  the  uterus,  but  on  a  line  rather  higher  than  the  one  on  the  front.  The  bladder 
has  been  stripped  awav  from  the  cervix  as  far  down  as  possible  by  sponge  pressure.  The 
posterior  peritoneum  has  been  stripped  down  toward  the  vaginal  portion  of  the  cervix  in  the 
same  manner.  The  broad  ligament  has  been  di^^ded  on  either  side  between  the  forceps,  and 
the  utero-ovarian  anastomoses  have  been  clamped  by  additional  forceps. 


389 


Figure  li 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  The  myomatous  corpus  uteri 
is  being  cut  from  the  cervix  by  means  of  scissors.  Observe  the  triangular  incision  is  directed 
not  in  the  lateral,  but  in  the  anteroposterior  direction.  The  tumor  having  been  removed, 
the  next  step  will  be  to  secure  the  uterine  and  ovarian  arteries  by  means  of  catgut  ligatures 
on  either  side.  This  having  been  done  the  forceps,  are  to  be  removed.  The  broad  ligaments 
and  the  two  sides  of  the  cervical  stump  are  then  to  be  brought  together. 


390 


Figure  189 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  Looking  down  on  the  cen-ical  stump 
and  severed  broad  ligaments  instead  of  looking  at  the  anterior  wall  of  the  cen-ix.  as  in  the 
pre\-ious  figure.  Uterine  and  ovarian  arteries  secured  by  ligature.  Two  running  catgut 
sutures  catching  up  the  peritoneal  covering  of  the  ceri'ical  stump  and  of  the  broad  Ugaments, 
one  anterior  and  one  posterior  to  the  cer^-ix  and  broad  ligaments,  have  been  passed  in  such 
a  manner  that  when  tied  they  will  draw  into  apposition  the  two  lateral  surfaces  of  the  cer%ical 
stump  and  will  unite  the  ligaments  end  to  end. 


391 


Fig  ORE  190 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  The  posterior  continuous  suture 
shown  in  the  previous  Figure  has  been  drawn  taut  and  tied.  The  anterior  suture  is  being 
drawn  taut  preparatory  to  tying. 


392 


FlQDRE    191 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  The  broad  ligaments  having  been 
drawn  together  as  shown  in  the  pre^nous  Figure,  the  approximation  is  completed  by  an  addi- 
tional running  catgut  suture  beginning  at  the  lower  end  of  the  line  of  union  on  the  posterior 
side  of  the  united  ligaments  and  continuing  over  the  edge  of  the  ligaments  down  on  the  anterior 
surface  to  the  bladder.     This  completes  the  closure  of  the  pelvic  wound. 


393 


Figure  192 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  The  corpus  uteri  has  been  removed, 
as  shown  in  the  previous  Figure.  The  uterine  and  ovarian  arteries  have  been  tied  with  catgut. 
The  cervical  stump  is  being  held  up  and  steadied  by  two  forceps  and  divided  anteroposteriorly 
into  two  equal  lateral  fragments  clear  into  the  vagina  by  means  of  scissors.  In  a  very  short, 
easily  dilatable,  patulous  cervix  the  uterine  dilator  introduced  from  above  downward  might 
be  used  to  divulse  the  Cervical  canal  widely  in  place  of  cutting  with  scissors. 


394 


FlGUIiE    103 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  The  cervix  having  been  divided  or 
dilated  as  explained  in  the  legend  of  the  pre\'ious  figure,  a  short  strip  of  gauze  is  introduced 
from  above  downward  into  the  vagina.  The  two  fragments  of  the  cervix  and  the  cut  ends 
of  the  broad  ligaments  are  then  ready  to  be  united  by  sutures.  The  first  suture  is  introduced 
but  not  tied.  The  operator  may  use  the  same  form  of  suture  as  shown  in  the  previous  figures, 
or  may  adopt  any  other  form  which  the  case  requires. 


395 


Figure  194 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  Continuation  of  the  previous  Figure. 
Vaginal  gauze  drain.  End-to-end  approximation  of  the  broad  ligaments  by  continuous 
suture.  This  suture  is  here  intended  to  suggest  a  method  of  closure.  Other  forms  of  suture 
and  methods  of  closure  are  permissible. 


396 


Figure  195 


Complete  Hysterectomy.  (Semidiagrammatie.)  The  myomatous  corpus  having  been 
removed  and  the  cervix  split,  the  two  lateral  fragments  are  being  removed  by  means  of 
scissors,  care  being  taken  to  keep  close  to  the  cervix  in  order  to  avoid  the  ureters. 


397 


Figure  190 


Complete  Hysterectomy.  (Semidiagrammatic.)  Continuation  of  the  previous  Figure. 
The  cervical  stump  having  been  removed,  the  cut  edge  of  the  vagina  is  drawn  up  by  means  of 
forceps  and  included  in  a  continuous  suture,  which  closes  the  upper  end  of  the  vagina  against 
the  united  broad  ligaments  which  are  brought  together  end  to  end.  This  form  of  suture  is 
here  introduced  to  show  a  method  of  union.  Other  forms  of  suture  may  be  better  suited  to 
individual  cases. 


398 


TlMOh'S   OF   THE    ITKIUS-^T liKATMEXT  OF   MYOMA        399 

Certain  j)oculiaritics  in  teciinicinc,  liowovtT,  should  he  obserN'ed  as 
follows: 

When  the  cervix  is  accessible  through  the  vagina,  the  first  incisions 
may  be  made  as  for  vaginal  hysterectomy,  the  bladder  and  the  rectum 
being  stripped  away  from  the  cervix,  if  practicable,  as  far  as  the  peri- 
toneal cavity.  The  broad  ligaments  may  be  separated  through  the 
vagina  and  tied  off  as  high  in  some  cases  as  the  uterine  arteries.  The 
extent  to  which  this  can  be  done  will  vary  with  the  individual  case. 
The  vagina  now  is  packed  temporarily  with  a  continuous  strip  of  gauze 
saturated  with  a  1 :  oOOO  70  per  cent,  alcoholic  solution  of  mercuric 
bichloride.  The  final  removal  of  the  uterus  through  the  abdomen  is 
facilitated  greatly  by  e\en  a  small  amount  of  vaginal  detachment. 
The  abdomen  then  is  opened  and  the  operation  continued  as  already 
described  for  supravaginal  hysterectomy;  the  uterine  arteries  usually 
are  clamped  and  tied  a  little  farther  from  the  uterus.  This  necessitates 
the  greatest  care  not  to  inclutle  the  ureters,  which  cross  the  arteries  very 
near  the  uterus.  The  broad  ligaments  and  circumuterine  structures 
then  are  divided  by  means  of  strong  scissors;  in  making  the  incisions 
for  this  purpose  close  to  the  uterus,  no  harm  is  done  if,  on  either  side, 
a  small  portion  of  the  lateral  wall  of  the  cervix  uteri  be  left  behind. 
The  bladder  is  stripped  away  from  the  cervix  as  far  toward  the  vagina 
as  practicable,  and  the  peritoneum  of  the  posterior  wall  of  the  uterus 
is  stripped  or  dissected  off  in  the  same  way. 

If  the  vaginal  incisions  previously  ha^•e  extended  into  the  pelvic 
cavity,  the  final  removal  of  the  uterus  will  be  easy.  If  the  incisions 
have  not  extended  so  far,  the  removal  will  not  be  difficult;  but  if  no 
vaginal  incisions  have  been  made,  the  operator  may  in  some  cases  find 
it  quite  tedious,  if  not  difficult,  to  work  his  way  down  into  the  vagina. 
The  attempt  has  resulted  occasionally  in  opening  the  rectum,  bladder, 
or  ureter.  This  difficulty  may  be  overcome  largely  by  a  simple  device 
which  has  been  used  by  the  author  for  several  years  with  great  satis- 
faction; the  operation  is  performed  as  follows: 

The  bladder  having  been  stripped  off  from  the  cervix  as  far  down 
as  possible  toward  the  vagina,  the  uterus  is  drawn  by  means  of  vul- 
sellum  forceps  well  up  into  the  abdominal  wound.  This  traction 
exposes  the  anterior  wall  of  the  cervix,  which  now  is  divided  freely 
with  sharp  scissors  by  a  longitudinal  incision  and  the  cervical  canal 
thereby  laid  open.  One  blade  of  the  scissors  is  passed  directly  down 
through  the  external  os  to  the  vagina,  dividing  the  entire  anterior 
cervical  w^all.  The  finger  now  readily  passes  to  the  vagina,  and  serves 
as  a  guide  for  the  rapid  removal  of  the  uterus  by  a  circular  incision 
around  the  cervix  at  the  uterovaginal  attachment.  In  some  cases  it 
is  convenient  to  reserve  ligature  of  the  uterine  arteries  to  this  part  of 
the  operation.    Small  bleeding  vessels  are  tied  or  twisted.    Figure  195. 

If  drainage  of  the  pelvic  cavity  is  required,  it  should  be  vaginal, 
and  the  vaginal  wound  should  be  left  open  or  partly  open  for  this  pur- 
pose. The  drain  is  introduced  as  follows:  the  end  of  a  long  strip  of 
gauze,  double  thick  and  two  inches  wide,  is  passed  from  the  pelvis 


400  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

through  the  vaginal  wuuikI  to  the  vulva;  then  this  continuous  strip  of 
gauze  is  packed  lightly  from  below  upward,  so  as  to  fill  the  vagina 
and  the  vaginal  wound,  and  to  cover  all  surfaces  in  the  pelvis  left 
exposed  by  the  operation.  The  dressing  over  the  vulva  which  receives 
the  capillary  drainage  from  the  gauze  should  be  kept  dry  by  fre- 
quent changing.  The  gauze  drain,  being  a  continuous  strip,  may  be 
removed  easily  through  the  vagina  in  two  or  three  daj^s. 

If  drainage  is  not  required,  the  wound  should  be  closed  completely 
both  on  the  vaginal  and  the  peritoneal  side.  This  may  be  done  by 
end-to-end  approximation  of  the  broad  ligaments  as  already  described 
for  supravaginal  hysteromyomectomy.  Figure  196  shows  the  upper 
cut  end  of  the  vagina  closed  by  side-to-side  union,  and  the  peritoneal 
part  of  the  wound  closed  by  end-to-end  approximation  of  the  broad 
ligaments.  The  same  sutures  that  unite  that  part  of  the  broad  liga- 
ments nearest  to  the  vaginal  wound  should  also  catch  up  the  upper 
cut  end  of  the  vagina  so  as  to  draw  it  into  the  space  from  which  the 
cervix  has  been  excised,  and  unite  it  to  the  lower  portion  of  the  broad 
ligament  stumps  at  or  near  the  point  where  the  ligatures  surround  the 
uterine  arteries;  this  serves  to  draw  the  vagina  strongly  upward  and  to 
cover  the  exposed  surfaces  between  the  vagina  and  broad  ligaments. 

Upon  completion  of  the  operation  the  vagina  having  been  packed 
with  a  gauze  strip  from  the  vaginal  wound  to  the  vulva,  a  large  gauze 
dressing  is  placed  over  the  vulva  to  absorb  any  wound  secretions.  And 
this  dressing  should  be  held  there  by  a  T-bandage,  and  changed  often 
to  keep  it  dry;  all  the  gauze  is  removed  in  about  three  days,  after 
which  low  pressure  vaginal  douches  of  0.5  per  cent,  lysol  are  given 
twice  a  day. 

In  hysteromyomectomy  the  ovaries,  if  normal  or  nearly  normal, 
should  be  preserved. 

In  all  operations  for  hysteromyomectomy  the  ligatures  and  sutures 
should  be  of  sterilized  catgut,  Claudius'  iodized  gut  preferred.  See 
Chapter  II. 


Advantages  of  Exd-to-exd  Approximation 

1.  The  broad  ligaments,  in  the  anatomical  sense,  take  the  place  of 
the  excised  uterus  and  form  a  pouch  posteriorly  like  the  cul-de-sac  of 
Douglas,  and  anteriorly  a  depression  that  answers  to  the  utero vesical 
pouch,  thus  conforming  to  the  normal  anatomy. 

2.  The  broad  ligaments,  thus  united,  together  with  adjacent  struc- 
tures, hold  up  the  rectum,  bladder,  vagina,  and  other  parts  of  the  pelvic 
floor,  and  in  so  doing  prevent  the  descent  of  these  organs,  which  so 
commonly  occurs  after  hysterectomy  as  ordinarily  performed. 

3.  The' broad  ligaments  and  adjacent  structures,  in  occupying  the 
space  left  by  complete  hysterectomy,  prevent  the  intimate  union  of  the 
rectum  and  bladder,  a  union  which  would  leave  only  a  thin  wall  between 
them  through  which  infection  might  pass  from  one  to  the  other. 


TUMORS  OF  THE   UTERUS— TREATMENT  Or  MYOMA        401 

4.  The    oixTiitioii    is    pert'oriiKMl    more   (.'usily    and    (Hiickly    l)v    this 
method  than  hv  tliat  of  transN-erse  siituriii^f  of  the  wounded  ligaments. 

5.  There  is  after  elosure  iiiueh  less  iiitra])eritoneal  traumatism  and 
consequently  less  danger  of  sepsis,  adhesions,  and  secondary  hemorrhage. 


Myomectomy  during  Pregnancy 

The  following  conditions  more  or  less  strongly  contraindicate  sur- 
gical treatment  during  pregnancy:  1.  Small  size  and  slow  growth  of 
the  tumor.  2.  Location  of  the  tumor  when  it  will  not  materially 
interfere  with  gestation  or  obstruct  delivery.  '.].  Probability  that  the 
tumor  will  rise  spontaneously,  or  that  it  may  be  forced  manually  out 
of  the  pelvis  into  the  abdomen,  when  it  will  not  interfere  with 
pregnancy  or  parturition.  The  opposite  of  these  conditions  may  call 
for  surgical  measures,  and  the  following  radical  measures  should  be 
considered : 

If  surgical  interference  is  inevitable,  and  gestation  has  not  advanced 
beyond  the  end  of  the  third  month,  the  indication  may  be  for  abor- 
tion. Interruption  of  gestation  at  this  time,  and  a  radical  operation 
for  the  removal  of  the  tumor  later,  may  be  the  safest  course. 

After  the  third  month  the  danger  of  induced  abortion  is  increased 
enormously.  This  increase  comes  from  infection,  from  hemorrhage, 
and  from  the  difficulty  of  delivering  the  placenta.  Csesarean  section, 
to  be  followed  immediately  by  complete  hysterectomy  or  supravaginal 
hysterectomy,  may  now,  in  the  interest  of  the  child,  be  deferred,  if 
possible,  to  the  period  of  viability^ — that  is,  to  the  end  of  the  seventh 
month  or  later. 

Removal  of  the  tumor  without  sacrificing  the  uterus  or  interrupting 
gestation  may  be  preferred  when  the  tumor  is  subperitoneal  and  re- 
movable with  small  uterine  traumatism.  This  operation  is  indicated 
especially  in  subperitoneal  pedunculated  tumors. 

An  infected  myoma,  especially  if  complicated  with  pregnancy,  demands 
immediate  radical  measures,  and  if  the  uterus  also  is  infected  may  call 
for  not  only  myomectomy,  but  for  hysterectomy  as  well. 


Prognosis  after  Operation  for  Myoma  Uteri 

Long-continued  menorrhagia  associated  so  commonly  with  uterine 
myomata  may  so  exhaust  the  woman  as  greatly  to  reduce  her  resist- 
ance, and  thereby  increase  the  danger  of  an  operation;  hence  the  occa- 
sional necessity  of  preparatory  treatment  as  already  described,  and 
delay  in  some  cases  for  weeks  or  months,  until  the  systemic  condition 
is  favorable.  If  before  an  abdominal  operation  the  haemoglobin  has 
been  brought  up  to  at  least  50  and  the  red  blood  count  to  not  less 
than  3,000,000,  the  danger  will  be  much  decreased.  Danger  in  the 
removal  of  a  uterine  myoma  varies  also  with  the  skill  of  the  operator, 
26 


402  TUMORS,    TUBAL   PREGNANCY,    MALFORMATIONS 

and  the  location  and  relations  of  the  tumor.  Removal  of  a  myoma 
from  the  infra  vaginal  portion  of  the  cervix  and  removal  of  intra-uterine 
myomata  through  the  vagina  are  practically  without  danger.  Under 
faVorable  conditions,  including  an  expert  surgeon,  a  mortality  of  5 
per  cent,  is  too  high. 

The  mortality  of  abdominal  myomectomy  and  hysteromyomectomy 
with  end-to-end  approximation  of  the  broad  ligaments,  and  drainage 
when  required,  as  described  in  this  chapter,  has  not  risen  above  1  per 
cent,  in  my  own  cases  during  the  last  ten  years. 


CHAPTER    XXV 
TUMORS  OF  THE   UTERUS 

CARCINOMA 

Etiology  of  Carcinoma  Uteri 

The  causes  of  cancer  are  unknown;  the  predisposing  or  favoring 
conditions  are  as  follov.s: 

1.  Age — the  disease  occurs  most  frequently  between  forty  and  fifty. 
The  extreme  hmitations  are  between  childhood  and  old  age. 

2.  Heredity — an  apparent  predisposing  cause. 

0.  Social  state — more  frequent  among  the  poor  and  ignorant. 

4.  Race — said  to  be  relatively  rare  among  negroes. 

5.  Trauma  of  labor — laceration  of  the  cervix  a  possible  predisposing 
cause. 

G.  Endometritis  and  endocervicitis  are  said  to  be  favoring  conditions. 

Pathology  of  Carcinoma  Uteri 

Carcinoma  may  arise  from  any  portion  of  the  uterine  mucosa,  i.  e., 
from  the  cylindrical  epithelium  which  lines  the  uterine  cavity  and 
dips  down  toward  the  muscularis  to  form  the  muciparous  glands  of 
the  uterus  or  from  the  pavement  epithelium  which  lines  the  vaginal 
portion  of  the  cer\-ix  uteri.  The  variety  of  carcinoma  usually  (not 
invariably)  corresponds  to  the  type  of  epithelium  from  which  it 
springs;  thus  may  be  distinguished  two  varieties: 

1.  Ci/Iindrical-cell  carcinoma,  adenocarcinoma,  gland  carcinoma  is 
that  variety  in  which  the  cylindrical-cell  gland  acini  of  the  interior 
of  the  corpus  or  cervix  uteri  multiply  in  an  atypical  manner,  break 
through  and  invade  the  interglandular  spaces  and  thus  conform  to  the 
carcinomatous  type. 

2.  Pavement-cell  carcinoma,  sqiiamons  carcinoma,  epithelioma,  is  that 
variety  in  which  the  pavement  epithelial  cells  (squamous  cells)  of  the 
^■aginal  position  of  the  cervix  uteri  have  multiplied  in  an  at^'pical 
manner  and  have  invaded  the  deeper  structures,  thus  forming  a  growth 
which  is  like  epithelioma  of  the  lip. 

From  the  above  it  may  be  inferred  that  carcinoma  of  the  endometrium 
or  cervical  cavity  is  of  the  cylindrical-cell  variety  and  that  carcinoma 
of  the  external  cervix  is  of  the  pavement-cell  variety.  This  rule  is  not 
invariable;  that  is,  cylindrical-eell  carcinoma  may  occur  below  or  the 
pavement-cell  variety  above  the  external  os.    Carcinoma  of  the  cervix 

( -403 ) 


404  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

originating  near  the  external  os  where  the  two  varieties  of  epithelium 
meet  may  conform  to  either  or  both  types.  When  the  deeper  struc- 
tures are  involved  in  carcinoma  the  affected  portion  is  enlarged,  hard, 
marble-like,  and  friable.  The  surface  is  smooth,  glistening,  and  flattened 
or  may  be  nodular.  Either  variety  rapidly  extends  and  ulcerates  early. 
The  margin  of  the  ulcer  is  irregular,  hard,  and  usually  raised.  The 
base  is  irregular  and  bleeds  easily.  The  ulcerative  process  may  destroy 
the  cervix  slowly  or  rapidly. 

Carcinoma  may  extend  frovi  the  cervix  uteri: 

1 .  To  the  vaginal  vault,  anteriorly  or  laterally,  less  often  posteriorly. 
The  advancing  margin  of  the  growth  is  raised,  rounded,  and  hard. 

2.  To  the  broad  ligaments,  giving  them  on  digital  touch  a  hard, 
board-like  feel. 

3.  To  the  vesicovaginal  septum,  less  often  to  the  rectum. 

4.  Rarely  to  the  uterine  appendages,  urethra,  or  pelvic  bones. 

5.  To  the  corpus  uteri — frequently. 

6.  To  the  iliac  glands — not  usually  until  the  disease  has  involved 
the  broad  ligaments;  this  delay  is  because  the  squamous  cancer-cells 
are  too  large  to  pass  easily  through  the  lymph-radicles  of  the  cervix, 
but  not  too  large  to  traverse  the  lymph-vessels  of  the  ligaments. 

7.  After  the  disease  has  passed  beyond  the  cervix  uteri  the  ureters 
usually  are  involved,  giving  rise  to  nephritis,  hydronephrosis,  or  pyelo- 
nephrosis.  Dilatation  of  the  ureters  is  the  common  result  of  inflam- 
matory constrictions  near  the  invading  growth,  pressure  of  the  growth 
on  the  ureter,  or  extension  of  the  growth  to  the  ureter. 

8.  Metastatic  cancer  extending  from  the  cervix  uteri  direct  to 
distant  organs  is  not  common. 

Carcinoma  may  extend  from  the  corpus  uteri: 

1.  To  the  broad  ligaments  and  parametria,  and  thence  to  any 
adjacent  structures,  such  as  peritoneum,  omentum,  mesentery,  intes- 
tine, Fallopian  tubes,  and  ovaries;  all  these  organs  being  involved, 
if  at  all,  in  the  later  stages;  complicating  cancer  of  the  liver  and  lungs 
is  rare. 

2.  To  the  lumbar  glands,  common;  to  the  inguinal  glands,  not  so 
common;  the  iliac  glands  are  less  liable  to  involvement  than  in  cancer 
of  the  cervix. 

3.  To  the  cervix  uteri. 

Symptoms  of  Carcinoma  Uteri 

There  are  no  incipient  symptoms,  nor  at  any  time  in  the  course  of 
cancer  are  the  symptoms  pathognomonic.  As  the  disease  progresses 
the  following  disorders  always  appear: 

1.  Hemorrhage. 

2.  Uterine  discharges. 

3.  Pain,  especially  in  advanced  adenocarcinoma. 

4.  Visceral  disorders. 

5.  Cachexia. 


T I  MORS  OF  THE  UTERUS  405 

1.  Hemorrhage  is  usually  the  first  syniptom,  and  is  the  result  of 
accidental  injury  to  the  cancer,  and  to  ulcerati\e  jjrocesses.  Infor- 
tunately  it  is  attriinited  often  to  irregularities  of  the  menopause  or  to 
a  return  of  menstruation  after  the  menopause;  hence  the  fact  that 
the  bleeding  of  carcinoma  often  is  disre^jarded  until  the  disease  has 
proi^ressed  beyond  the  hope  of  cure.  The  reappearance  of  hemor- 
rhage one,  two,  three,  or  more  years  after  the  menojxiuse  raises  a  ques- 
tion of  cancer,  and  demands  immediate  examination.  The  loss  of  blood, 
at  first  slight,  is  noticed  commonly  after  straining  at  stool,  or  vigorous 
exercise,  or  coitus.  With  the  progress  of  the  disease  the  hemorrhage 
increases;  it  may  be  nearly  or  quite  constant,  may  occur  at  irregular 
intervals,  or  in  the  form  of  menorrhagia  at  the  catamenia.  Usually 
the  patient's  strength  is  exhausted  slowly  by  a  persistent,  slow  seeping 
away  of  watery  blood.  On  the  other  hand,  sudden  profuse,  even 
dangerous,  hemorrhages  are  possible.  The  menstrual  history  bears 
no  very  significant  relation  to  the  development  of  carcinoma.  The 
disease  in  many  cases  follows  the  menopause. 

2.  Uterine  Discharge. — The  character  of  the  discharge  varies  with 
the  progress  of  the  disease  as  follows: 

a.  Early;  discharge  watery,  bloody,  serous,  transparent,  inodorous. 

h.  Later;  discharge  watery,  bloody,  and  foetid. 

c.  As  ulceration  increases  and  the  growth  becomes  friable,  the  dis- 
charge is  more  profuse,  bloody,  turbid,  sometimes  purulent,  and  of 
a  most  nauseating  odor.  This  latter  symptom  continues  more  or  less 
constant  to  the  end,  and  is  characteristic  of  malignancy.  The  dis- 
charge is  called  "carcinomatous  ichor,"  or  "cancer  juice."  All  ex- 
cessive discharges,  especially  after  the  menopause,  should  be  regarded 
with  suspicion. 

3.  Pain  is  rarely  present  while  the  growth  is  confined  to  the  vaginal 
portion  of  the  cervLx.  Involvement  of  the  corpus  uteri  and  of  the 
structures  around  the  uterus  may  give  rise  to  sharp,  lancinating  pains. 
These  pains,  although  often  described  as  pathognomonic,  are  by  no 
means  constant  or  confined  to  cancer.  They  may  be  supplemented 
by  the  pains  of  pelvic  peritonitis.  The  peritonitis  in  a  limited  degree 
protects  the  general  peritoneum  by  adhesions  which  form  in  front  of 
the  invading  carcinoma.  The  pains  are  due  to  pressure  on  the  pelvic 
nerves  or  to  actual  involvement  of  those  nerves  in  the  carcinoma: 
they  commonly  are  referred  to  the  region  of  the  pelvis,  perineum,  or 
thighs,  and  usually  indicate  that  the  disease  is  past  operative  cure. 
The  retention  of  secretions  in  the  uterus  from  occlusion  of  the  cervical 
canal  by  the  invading  carcinoma  may  give  rise  to  hydrometra  or 
pyometra,  and  cause  spasmodic  expulsive  uterine  pains  like  labor-pains. 

4.  Visceral  Disorders  may  be  consequent  upon  pressure  or  invasion 
of  neighboring  organs.  The  bladder  becomes  irritable.  Vesical  catarrh, 
strangury,  painful  urination,  pyuria,  and  cystitis  may  follow.  Vesico- 
uterine or  vesicovaginal  fistula  may  result  from  destructive  ulcera- 
tive processes.  Uretero-uterine  and  ureterovaginal,  recto-uterine  and 
rectovaginal  fistula  may  occur  in  the  same  way.      Nephritis,  uraemia, 


406  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

h^'dronephrosis,  and  atrophy  of  the  kidney  are  among  the  not  unusual 
resultant  complications.  Constipation  is  explained  as  follows:  First, 
the  patient,  through  fear  of  pain  and  bleeding,  voluntarily  retains  the 
feces;  second,  the  feces  becomes  dry  and  hard  from  loss  of  water  in 
the  ichorous  discharges;  third,  the  bowel  is  incapacitated  by  the  disease 
for.  the  ready  expulsion  of  its  contents.  Diarrhoea  may  be  caused  by 
irritation  of  the  bowel  from  the  invasion  of  the  cancer.  Alternating 
constipation  and  diarrhoea  are  not  uncommon. 

5.  Cachexia  appears  not  very  late  in  the  course  of  the  disease,  and  is 
a  characteristic  symptom.  It  is  marked  by  emaciation,  a  yellowish 
pallor  of  the  skin,  profound  anaemia,  and  great  depression  of  both 
mind  and  body.  It  is  caused  by  toxic  agents  elaborated  by  the  malig- 
nancy giving  rise  to  perverted  metabolism  and  by  malnutrition  due 
to  anorexia,   vomiting,   pain,   and  hemorrhage. 

Diagnosis  of  Carcinoma  Uteri 

The  earlier  the  carcinomatous  uterus  is  removed,  the  less  the  likeli- 
hood of  recurrence;  hence  the  earliest  possible  diagnosis  is  imperative. 
Absolute  diagnosis  must  depend  usually  upon  the  microscopical  findings. 
A  probable  diagnosis  often  may  be  made  by : 
1.  The  clinical  history. 

■^  2.  The  physical  signs. 

1.  The  Clinical  History,  as  indicated  in  the  foregoing  paragraphs, 
gives  strong  evidence  though  not  proof  of  cancer. 

2.  The  Physical  Signs  are  demonstrated  by  conjoined  examination 
and  inspection.  The  extremely  foetid  odor,  which  clings  to  the  examin- 
ing  finger  despite  much  washing  and  the  energetic  use  of  the  nail-brush, 
and  which  usually  may  be  avoided  by  the  free  use  of  glycerin  as  a  lubri- 
cant, is  characteristic.  Infiltrating  carcinoma  of  the  cervix  is  recog- 
nized as  a  thick,  usually  hard,  more  or  less  nodular  friable  growth. 
The  friability  and  bleeding  are  almost  pathognomonic.  The  ulcers, 
if  present,  have  an  irregular,  hard,  raised  margin,  and  uneven  base, 
and  bleed  freely  upon  slight  injury.  Before  ulceration  the  surface 
appears  even  or  nodular,  marble-like  and  glistening.  After  ulceration 
the  surface  is  ragged  and  irregular,  and  may  show  large  excavations 
from  the  sloughing  of  carcinomatous  tissue.  In  this  way  the  entire 
cervix  may  be  destroyed.  A  papillomatous  superficial  variety  appears 
as  a  soft,  friable,  bleeding,  cauliflower-like  mass. 

Diagnosis  of  Carcinoma  of  the  Cervix  Uteri. — Early  carcinoma  of 
the  cervix  without  great  care  may  be  overlooked.  The  cervical  wall 
around  the  external  os  may  be  only  a  little  thickened  ©n  the  affected 

Explanation  op  Plate  XV 

A.  Carcinoma  of  the  corpus  uteri  complicated  with  small  multiple  myomata. 

B.  Carcinoma  of  the  corpus  uteri.  On  the  right  side  the  disease  has  extended  nearly  through  the 
uterine  wall:  on  the  left  side  the  disease  is  confined  apparently  to  the  mucosa,  and  in  gross  appearance 
resembles  polypoid  endometritis. 

C.  Carcinoma  of  the  cervix  uteri,  the  cervix  nearly  destroyed. 

D.  Carcinoma  of  the  cervix  uteri,  the  cervix  wholly  destroyed. 


PLATE    XV 


PLATE    XVJ 


FIGURE   1 


^^0€j&^&^:-fi^^^ 


>!- .. 


FIGURE  2 


FIGURE  S 


'li^' 


mm 
mm 


M,. 


"^- 


"PA'n  kfcr.  • 


a 


TUMORS  OF  THE  UTERUS  407 

side.  Tlie  indurated  tissue  mny  appear  almost  insignificant  in  amount. 
Extreme  friability  and  ])ersistent  bleedinj^  on  sli<j:ht  abrasion  will, 
however,  be  strong  diagnostic  factors.  Subjective  symptoms  may  be 
absent.  Excision  of  a  small  piece  for  microscopical  examination  is 
now  imperative.  This  should  be  wedge-shaped,  and  should  include  a 
portion  of  the  surrounding  healthy  tissue.  The  slight  wound  may  be 
closed  by  one  or  two  sutures.  Cervical  scrapings  may  be  useless  for  ex- 
amination. Cerviqal  carcinoma  has  been  shown  by  reliable  statistics 
to  be  about  sixteen  times  more  frequent  than  carcinoma  of  the  corpus 
uteri. 

Diagnosis  of  Carcinoma  of  the  Corpus  Uteri. — Carcinoma  of  the 
corpus  uteri  is  in  the  beginning  often  impossible  to  recognize.  It  is  apt 
to  appear  between  the  ages  of  forty  and  fifty.  There  is  increased  and 
irregular  menstruation,  which  often  is  attributed  wrongly  to  the  meno- 
pause. The  presence  of  a  slight  watery  discharge,  even  though  odorless, 
is  highly  diagnostic.  If  the  discharge  is  very  fetid,  the  evidence  is  much 
stronger.  The  general  tone  of  the  patient  may  be  almost  up  to  the 
normal  standard.  Conjoined  examination,  preferably  with  rubber 
gloves,  shows  nothing  except  perhaps  slight  enlargement  of  the  uterus. 
Life  now  may  depend  upon  speedy  diagnosis.  The  whole  question  cen- 
tres in  the  product  of  curettage  and  the  microscopical  findings..  Should 
no  microscopical  evidence  of  cancer  be  found,  the  curettage  should  be 
repeated  whenever  the  hemorrhage  reappears.  In  cancer  the  dis- 
charge ahvays  recurs  promptly.  The  scrapings  are  usually  much 
more  abundant  than  in  benign  growths. 

Frequently  recurring  glandular  hyperplastic  endometritis  with  much 
cystic  development  after  repeated  curettage,  especially  if  associated  with 
free  hemorrhage  and  a  watery  discharge,  should  give  rise  to  grave  appre- 
hension,  and  would  justify  removal  of  the  uterus  on  suspicion. 

Advanced  carcinoma  of  the  body  of  the  uterus  is  recognized  by  the 
symptoms  already  described  and  by  conjoined  examination.  The 
uterus  is  enlarged — often  tw^o  or  more  times  its  normal  size.  It  is 
hard,  nodular,  and,  in  the  later  stages,  more  or  less  fixed.  Early  fixa- 
tion also  occurs  in  cervical  cancer.  The  causes  of  fixation  are  similar 
to  those  which  produce  the  same  condition  in  pelvic  inflammation 
— i.  e.,  extension  of  the  disease  to  the  parametria.  The  lower  extremi- 
ties become  oedematous  later  from  hydrsemia,  from  pressure,  and  from 
thrombosis  of  the  pelvic  veins.  The  absolute  diagnosis  may  have  to 
depend  upon  the  microscope.    The  recognition,  however,  of  advanced 

Explanation  of  Plate  XVI 

Figure  1. — Mucous  membrane  of  the  cervix  uteri  in  section  taken  just  above  the  external  os, 
showing,  A,  the  branching  racemose  ghmd  dips  down  from  the  free  mucous  surface  to  the  muscularis. 
15  diameters. 

Figure  2. — A  magnified  reproduction  of  gland  .i  in  Figure  1.  Observe  the  horny  layer  at  B,  the 
cuboidal  epithelium  at  C.  and  the  papillary  layer  at  D.     60  diameters. 

Figure  3. — Pavement-  or  squamous-cell  carcinoma.  A  hypothetical  pavement-cell  carcinoma 
is  here  shown  as  it  would  appear  if  it  attacked  gland  A  in  Figure  2.  The  two  deep  pockets  of  gland  A 
are  normal,  but  the  remainder  of  the  gland  has  been  invaded  by  squamous  epithelium,  of  which  the 
nuclei  are  stained  deeply  and  packed  closely  together.  The  surrounding  stroma  is  infiltrated  with 
small  roimd  cells.  Invasion  of  the  gland  in  this  manner  by  squamous  epithelium  establishes  the 
diagnosis  of  carcinoma.  Two  normal  blood-vessels  are  shown  in  the  lower  part  of  the  Figure.  Dia- 
grammatic.    60  diameters. 


408  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

carcinoma,  whether  of  the  cervix  or  corpus,  even  without  the  micro- 
scope, is  usually  not  difficult.     "  He  who  runs  may  read.'' 

Diagnosis   of  Extension  of  Carcinoma  Uteri. — Carcinoma   of  the 
uterus  may  extend  to  adjacent  and  other  organs  as  follows: 

1 .  Extension  to  the  Vagina,  recognized  by : 

a.  Cartilage-like  hardness  and  nodules  in  the  vaginal  vault, 

due  to  carcinomatous  infiltration. 
h.  Ulcers  in  vaginal  vault  having  hard  border  and  bleeding  base. 

2.  Extension  to  the  Rectum,  recognized  by: 

a.  Bloody,  offensive  discharge  from  rectum. 

h.  Rectal  touch  shows  irregular  hard  post-uterine  mass  extend- 
ing into  rectal  wall. 

c.  Rectal  mucosa  fixed  to  mass  and  ulcerated;  borders  of  ulcer- 
ated surfaces  hard  and  raised. 

3.  Extension  to  Bladder,  recognized  by: 

a.  Cystoscopy,  conjoined  examination,  digital  touch. 
h.  Hsematuria. 

4.  Extension  to  Parametria,  recognized  by  the  following  conditions: 

a.  Cancerous  infiltrate  usually  is  harder  than  inflammatory 
infiltrate.  The  inflammatory  infiltrate,  unlike  that  of  car- 
cinoma, first  forces  the  uterus  to  the  opposite  side,  and  later, 
as  the  mass  disappears,  contracting  structures  draw  it 
toward  the  aft'ected  side.  Fixation  of  the  uterus  is  not 
a  reliable  sign,  because  the  uterus  may  also  be  fixed  by 
inflammatory  infiltrate. 

6.  Carcinoma  of  the  supravaginal  portion  of  the  cervix  gives 
rise  to  early  infiltration  of  the  parametria;  carcinoma  of 
the  infravaginal  portion  causes  this  later,  and  carcinoma 
of  the  corpus  still  later. 

c.  Hard  mass  extends  first  from  posterior  wall  of  the  cervix 
to  the  back  of  the  pelvis,  later  to  the  sides;  best  palpated 
through  the  rectum. 

5.  Extension  to  the  Glands: 

a.  The  iliac  glands  are  the  first  to  be  involved  in  cancer  of 
the  cervix,  and  are  palpated  best  under  narcosis  per  rectum, 
in  front  of  the  sacro-iliac  joint;  infiltration  of  the  para- 
metrium precedes  infiltration  of  the  glands. 

h.  The  lumbar  glands  involved  in  cancer  of  the  corpus  uteri 
are  palpated  with  difficulty,  only  under  anaesthesia  through 
the  abdominal  w^alls  when  the  walls  are  thin  and  relaxed. 

6.  Extension  by  Metastasis  to  other  organs  is  a  late  manifestation, 

of  which  an  early  positive  diagnosis  is  impossible. 

7.  Diagnosis  of  Recurrence  of  Cancer  after  Removal.     After  hyster- 

ectomy, recurrence  may  be  suspected  under  the  following 
conditions : 

a.  Pain  radiating  to  hip  and  thigh. 

b.  (Edema  in  lower  extremities. 

c.  Cachexia  and  failing  health. 


PLATE    XVII 


^i^p^'^'rf^^i 


■  ^ 


^^^?f?? 


g 


i_  (»/*-^ 


1 1 1    ^  ^i- 

Itk^ u?i  ^  Wo  t-c      c 


'^' 


^-  ( 


-*-^^" 


-«-v 


^ 


3=s^ 


Adenocarcinoma  of  the  Corpus  Uteri. 

In  the  lower  middle  part  of  the  drawing  is  a  longitudinal  section  of  a  normal 
gland.  In  the  four  comers  are  glands  marked  a'  a"  a'"  which  have  many  la^-ers 
of  epithelium  still  confined  within  the  glands.  Occupying  the  centre  of  the  draw- 
ing is  an  enormously  large  gland  the  right  half  of  which  (g)  is  nearly  normal,  but 
the  left  half  shows  three  branches  (b  b  b)  in  which  there  is  very  great  prolifera- 
tion of  epithelium  filling  that  part  of  the  gland  cavity  and  invading  the  stroma 
between  the  branches.  The  great  proliferation  of  cells  at  b  b  b  and  the  invasion 
gland  structure  into  the  stroma  establish  the  diagnosis  of  carcinoma.  The  char- 
acteristic small  round-cell  infiltration  around  the  carcinomatous  area  is  present. 
150  diameters. 


TUMORS  OF   THE   UTERUS 


409 


Differential  Diagnosis  of  Carcinoma  Uteri. — The  conditions  most 
liable  to  be  mistaken  for  carcinoma  are: 


Myoma. 

Sarcoma. 

Retained  placental  tissue. 

Hypertrophy  of  the  cervix. 

Endocervicitis.     Xabothian 

follicles. 
Endometritis. 


Syphilis. 

Chronic  metritis. 

Ichthyosis. 

Tuberculosis. 

Laceration  of  the  cervix  uteri. 

Endothelioma. 

Arterial  sclerosis. 


The  differential  diagnosis  will  be  found  in  the  following  parallel 
columns  and  paragraphs: 


Advance<i  carcinoma  of  the  corpus  uteri 

1.  Cachexia,   hemorrhage,    and   very   foul   dis- 
charges. 

2.  Sloughing  tissues  very  friable. 

3.  Cerv-ix  may  be  involved  by  extension. 

4.  Characteristic  epithelial  proliferations  seen 
by  microscope. 

Carcinoma  uteri 

1.  Frequent. 

2.  Diffuse. 

3.  Surface  not  smooth. 

4.  Trabeculse  seen  on  cross-section. 

5.  Gland  formation,  abundant  stroma,  blood- 
vessels with  walls  in  stroma. 


Carcinoma  of  the  corpus  uteri 

1.  History  of  pregnancy  commonly  absent. 

2.  Hemorrhage  from  uterus.     Watery. 

3.  Quantity  of  tissue  removed  by  curette  may 
be  large. 

4.  Scrapings  composed  of  short,  friable  threads 
having  a  shaggy  appearance. 

5.  Microscopical  examination  shows  carcinoma. 

6.  Cachexia. 

Carcinoma  of  the  cervix  uteri 

1.  Cerv'ix     enlarged,     friable,     breaks     down 
rapidly  and  bleeds  freely  to  touch. 

2.  Characteristic    offensive    waterj-    discharge 
— "cancer  juice. " 

3.  Microscopical  examination  of  excised  portion 
shows  carcinoma. 


Sloughing  submucous  myoma 

1.  Anaemia   from   hemorrhage;   discharges  less 
foul. 

2.  Tough,  not  friable. 

3.  Cervix  not  so  involved. 

4.  Absent. 


Sarcoma  uter\ 

1.  Very  rare. 

2.  Rather  sharply  defined. 

3.  Previous  to  necrosis  surface  usually  smooth. 

4.  Cross-section  shows  smooth,  homogeneous 
surface. 

5.  Cells  round  or  spindle-shaped,  httle  or  no 
stroma:  in  place  of  bloodvessels  with  walls  there 
are  blood  spaces  in  direct  relation  with  surround- 
ing cells. 

Retained  placental  tissue 

1.  Historj-  of  recent  pregnancy. 

2.  Same.     Less  watery. 

3.  Quantity  always  large. 

4.  Scrapings  composed  of  mjTiads  of  long, 
slender  threads  ha-\-ing  shaggj;  appearance. 

.5.  Microscopical  examination  shows  products 
of  conception. 

6.  Anfflmia. 

Hypertrophy  of  the  cervix  uteri 

1.  Cer\-ix  enlarged,  tough,  and  does  not  bleed 
freelv  to  touch. 

2.  "Absent. 

3.  Shows  cersdcal  structures  modified  only 
by  hjTDertrophy. 


Endocervicitis. — Cystic  and  polypoid  glandular  enlargements  due 
to  endocervicitis  have  certain  characteristics  which  might  lead  one  to 
mistake  them  for  cancer. 

Cystic  glandular  enlargement  (cystic  degeneration)  of  the  Xabothian 
follicles  may  be  distinguished  from  cancer  by  the  following  char- 
acteristics: 1.  The  large,  hard  nodular  cervix  is  smooth,  non-friable, 
and  has  no  tendency  to  bleed.  2.  Puncture  of  cysts  reveals  mucous 
contents.  3.  Progress  of  disease  very  slow.  4.  ^licroscopical  section 
shows  cysts  lined  with  a  single  layer  of  epithelium,  with  tunica  propria 
unbroken  and  surrounded  by  normal  stroma.  5.  Condition  generally 
due  to  laceration  of  cervix  and  eversion  of  the  cervical  mucosa. 

Polypoid  glandular  enlargement  (mucous  polypi)  differs  from  car- 
cinoma in  the  following  particulars:     1.    Springs   from    area   within 

25 


410  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

cervical  canal.  2.  Lips  of  cervix  intact.  3.  Polypi  rather  firm,  not 
friable,  and  bleed  but  little.  4.  Microscopical  section  shows  single 
layer  of  epithelium  and  normal  or  hypertrophied  cervical  glands. 

Endometritis. — The  microscopical  differential  diagnosis  has  been  set 
forth  in  the  chapter  on  Endometritis.  See  clinical  diagnosis  of  the  two 
diseases,  as  presented  in  the  same  chapter.  Polypoid  endometritis 
is  distinguished  from  carcinoma  of  the  corpus  uteri  by  the  following 
characteristics:  1.  Polypoid  eminences  not  sharply  defined.  2.  Fria- 
bility not  marked.     3.  Underlying  muscularis  not  invaded. 

Syphilis  will  be  known  by  the  clinical  history.  In  doubtful  cases 
the  Wassermann  test  should  establish  the  diagnosis. 

Chronic  Metritis. — Chronic  metritis  shows  a  history  of  inflammation, 
is  associated  usually  with  endometritis,  does  not  cause  the  carcino- 
matous cachexia  nor  the  offensive  watery  discharge.  On  conjoined 
examination  the  uterus  is  symmetrical,  while  a  carcinomatous  uterus 
is  usually  nodular. 

Ichthyosis  Uteri. — This  condition  is  marked  by  the  presence  of  two 
or  more  layers  of  stratified  epithelium;  in  the  cavity  of  the  uterus  it 
has  been  observed  in  connection  with  inversion  of  the  uterus,  with 
cervical  polypi,  and,  according  to  Zeller,  with  chronic  endometritis. 
Transition  of  columnar  to  pavement-cell  epithelium  occurs  in  hydro- 
metra  and  hsematometra,  and  in  extra-uterine  pregnancy;  the  trans- 
formation may  occur  when,  from  any  cause,  the  mucosa  is  stretched 
and  fastened,  so  as  to  stratify  the  epithelium.  The  condition  gives  rise 
to  no  unusual  symptoms  except  such  as  ordinarily  would  be  observed 
in  endometritis  or  in  the  beginning  of  carcinoma  of  the  corpus  uteri. 
The  scrapings  of  stratified  epithelium  under  the  microscope  may  have 
a  similar  appearance  in  ichthyosis  uteri  and  carcinoma  uteri.  If  the 
microscopical  findings  show  that  the  stratified  epithelium  is  limited 
to  the  superficial  structures,  the  case  is  one  of  ichthyosis  uteri.  If  the 
epithelium  penetrates  the  underlying  connective  tissue,  or  muscular 
layer,  and  if  that  epithelium  is  surrounded  by  round-cell  infiltration, 
the  disease  is  probably  carcinoma.  Just  as  glandular  hypertrophy 
may  be  the  starting-point  of  carcinoma,  so  may  ichthyosis. 

Tuberculosis  of  the  Uterus. — Tubercular  disease  in  the  uterus  varies, 
and  is  rare  according  to  location. 

Tuberculosis  of  the  endometrium  is  distinguished  from  carcinoma  by 
the  following  characteristics: 

1.  Mucosa  at  first  smooth,  yellowish  white,  and  glistening;  later, 
yellowish-white  nodules  appear  on  surface  and  below  surface  of 
endometrium. 

2.  Finally,  nodules  undergo  caseous  degeneration  and  ulceration. 

3.  At  times  small  yellowish  tubercles  surround  ulcers. 

4.  Disease  may  involve  entire  endometrium  and  may  extend  through 
the  muscularis  to  the  perimetrium. 

5.  Hemorrhage  not  characteristic. 

Tuberculosis  of  the  cervix  presents  the  characteristic  ulcerative 
processes  of  lupus. 


TUMORS  OF   THE   UTERUS  411 

1.  Margins  of  ulcers  arc  well  definied,  or  may  he  uiidcrminefl,  and 
are  surrouiuled  by  tuhereles. 

2.  Base  of  ulcers  is  studded  with  tubercles  and  co\ered  with  pus, 
necrotic  tissue,  or  caseous  matter. 

'A.  Microscopical  section  shows  cells  and  tubercle  bacilli. 

Tuberculosis  diti'ers  from  carcinoma  in  all  the  above  particulars. 

Laceration  of  the  Cervix  Uteri. — This  condition  is  characterized  by 
iuHannnatory  and  mechanical  results  which  may  resemble  closely 
carcinoma  of  the  cervix.    They  are: 

1.  Eversion  of  the  intracervical  mucosa  and  cystic  degeneration  of 
the  Xabothian  follicles  (see  Endocervicitis,  in  one  of  the  fore(,^oing 
paragraphs). 

2.  The  everted  eroded  surfaces  present  an  irregular  and  sharply 
defined  line  of  demarcation. 

3.  Approximation  of  the  lacerated  margins  by  means  of  tenacula 
causes  the  everted  mucosa  to  be  rolled  in  and  to  disappear. 

4.  The  cervix,  if  indurated,  presents  the  peculiar  hardness  of  hyper- 
trophy; not  the  friability  of  carcinomatous  infiltration. 

5.  In  all  the  above  particulars  this  condition  differs  from  cancer. 
In  doubtful  cases  microscopical  examination  is  essential. 

Endothelioma  is  a  very  rare  malignant  new  formation  arising  from 
the  endothelium  of  blood-vessels,  or  of  lymph-vessels,  or  of  serous 
surfaces;  it  closely  resembles  carcinoma  in  gross  appearance  and  clin- 
ical manifestations.  The  entire  lumen  of  the  vessel  is  distended  with 
proliferating  endothelium,  wdiich  assumes  a  variety  of  shapes.  The 
cells  usually  form  nests  and  strands  similar  to  those  of  carcinoma.  The 
diagnostic  point  is  the  origin,  as  stated  above.  The  diagnosis  can 
be  made  only  by  microscopical  examination.  The  growth  is  found  in 
the  cervix  and  corpus  uteri,  and  very  rarely  also  in  the  ovary,  Fallo- 
pian tube,  and  vagina,  since  the  treatment  is  the  same  as  that  of  other 
malignant  disease,  the  diagnosis  is  a  matter  of  scientific  rather  than 
of  clinical  moment. 

Arterial  Sclerosis  of  the  uterus  is  a  rather  common  affection  in  w^omen 
who  have  passed  the  menopause,  and  sometimes  gives  rise  to  very 
erratic  uterine  hemorrhage.  Like  cancer  it  may  be  associated  w^ith 
considerable  enlargement  and  hardening  of  the  uterus.  It  does  not 
render  the  uterus  nodular  as  cancer  sometimes  does,  nor  does  the 
sclerotic  uterus  give  forth  the  characteristic  ichorous,  watery  dis- 
charge of  cancer  with  the  associated  cachexia  of  malignancy.  Cancer 
on  curettage  sho^vs  usually  an  abundance  of  curetted  material,  which 
on  microscopical  examination  will  be  positively  diagnostic.  Arterial 
sclerosis,  on  the  contrary,  shows  very  little  product  of  curettage,  which 
on  microscopical  examination  will  have    no  resemblance  to  cancer. 

Prognosis  of  Carcinoma  Uteri 

The  sole  hope  of  radical  cure  is  in  surgical  removal  of  the  carcinoma. 
Except  for  palliation,  drugs  are  useless.     If  the  growth  has  progressed 


412  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

beyond  the  limits  of  a  radical  operation,  "All  hope  abandon  ye  who 
enter  here."  The  disease  sometimes  will  destroy  life  in  a  few  months 
or  weeks;  it  may  for  a  time  become  apparently  inactive,  or  develop 
very  slowly,  and  then  go  on  to  a  rapid  termination.  Apparently  this 
rule  admits  of  rare  exceptions,  i.  e.,  reports  of  spontaneous  cure  have 
been  recorded,  doubtless  in  most  instances  due  to  wrong  diagnosis. 
The  prognosis  as  to  limit  of  life  should  be  guarded.  A  general  state- 
ment that  death  is  more  liable  to  occur  within  one  year  than  after 
two  years  usually  will  be  safe. 

The  causes  of  death  are  exhaustion,  sepsis,  hemorrhage,  uraemia,  inter- 
current diseases,  such  as  peritonitis  and  pneumonia.  Hemorrhage, 
although  it  may  exhaust  the  vitality  slowly,  is  rarely  a  direct  cause  of 
death.  Fatal  peritonitis  seldom  occurs  from  extension  of  the  disease. 
In  the  vast  majority  of  cases  death  is  from  marasmus  or  ureemia,  or 
both.  Fatal  septic  pneumonia  and  pulmonary  oedema  may  be  caused 
by  embolism. 

Treatment  of  Carcinoma  Uteri 

The  treatment  is  radical  when  the  cancer  has  not  extended  beyond 
the  limits  of  entire  removal;  palliative,  when  it  cannot  be  removed 
entirely.  The  radical  treatment  should  always  be  complete  hyster- 
ectomy. The  old  practice  of  high  amputation  of  the  cervix  for  cervical 
cancer  should  never  be  resorted  to,  for  one  can  never  be  certain  that 
the  disease  is  not  also  present  and  unrecognized  in  the  corpus  uteri. 

Hysterectomy  always  is  indicated  if  the  carcinoma  is  limited  to  the 
uterus;  such  limitation  may  be  possible  if: 

1.  The  uterus  is  normally  mobile  and  symmetrical. 

2.  The  uterus  is  not  excessively  enlarged. 

3.  The  iliac  and  lumbar  lymphatic  glands  are  not  enlarged;  this 

is  difficult  to  determine  before  operation. 

4.  The  vaginal  wall  is  not  involved  in  carcinoma. 

5.  The  parametria  are  not  infiltrated,  as  shown  by  vaginal  and 

rectal  examination. 

The  reverse  of  the  above  conditions  weakens  the  indication  for 
hysterectomy;  the  stronger  the  reverse  the  weaker  the  indication. 

Enlargement  of  the  glands,  although  evidence  that  carcinoma  has 
extended  beyond  the  uterus,  does  not  necessarily  contraindicate  hyster- 
ectomy, although  it  renders  the  prognosis  less  favorable.  Such  enlarge- 
ment may  be  due  to  inflammatory  infection,  and  not  to  extension  of 
carcinoma.  Further  discussion  of  this  part  of  the  subject  follows 
under  Radical  Abdominal  Hysterectomy  in  this  chapter. 

Extension  of  cancer  to  the  vaginal  walls,  if  slight,  does  not  definitely 
contraindicate  hysterectomy,  provided  the  diseased  portion^  of  the 
vagina  can  be  removed  together  with  the  uterus.  Extensive  involve- 
ment of  the  vagina  and  fixation  of  the  uterus  in  surrounding  cancer 
contraindicate  the  radical  operation. 

When  the  disease  has  passed  beyond  the  hope  of  radical  cure,  but 
not  beyond  the  limits  of  palliative  operation,  hysterectomy  is  per- 


TUMORS  OF  THE   UTERUS  413 

formed  sometimes  for  the  temporary  relief  of  symptoms;  the  benefits, 
however,  usually  are  not  sufficient  to  overbalance  the  dangers.  The 
removal  of  a  carcinomatous  cervix  alone  by  galvanocautery  as  a 
radical  operation  usually  is  inadequate;  as  a  palliative  measure  in 
advanced  carcinoma  it  may  furnish  temporary  relief. 

Hysterectomy. — Hysterectomy  for  carcinoma  uteri,  whether  per- 
formed b>'  vaginal  or  abdominal  section  or  by  combined  vaginal  and 
abdominal  section,  should  be  complete;  that  is,  it  should  completely 
remove  at  least  the  entire  uterus.  Up  to  recent  times  the  most  com- 
mon operation  has  been  ordinary  vaginal  hysterectomy — substantially 
the  operation  described  in  Chapter  XX.,  on  the  Treatment  of  Pelvic 
Inflammation.  This  operation,  although  having  almost  no  mortality, 
per  se,  has  fallen  under  criticism  because  of  the  discouraging  percentage 
of  recurrences  at  the  site  of  the  operation.  Consequently,  radical 
efforts  have  been  made  to  modify  it  in  such  a  way  as  to  increase  the 
percentage  of  permanent  cures.  Taking  the  operation  as  described 
in  Chapter  XX.,  as  a  point  of  departure,  one  must  consider  how 
much  farther  it  is  practicable  to  go  in  the  removal  of  broad  ligaments 
and  pelvic  and  lumbar  glands,  how  far  traumatism  and  difficulty  of 
technique  may  be  increased,  to  what  extent  the  duration  of  the  opera- 
lion  may  be  prolonged  without  adding  enough  immediate  mortality  to 
offset  any  possible  advantage  accruing  from  increased  freedom  from 
recurrence. 

In  estimating  the  merits  of  different  operations,  one  must  have  in 
mind  constantly  the  rule  w^hich  applies  to  the  removal  of  cancer  in 
other  regions;  that  is,  complete  removal  of  all  apparently  diseased  tissue 
and  of  as  ivide  a  margin  of  adjacent  tissue  as  prudence  will  permit;  this 
rule  is  based  upon  the  invariable  tendency  of  cancer  to  follow  lymph- 
channels  into  surrounding  structures  and  to  invoh'e  neighboring 
lymphatic  glands.  The  above  considerations  lead  to  a  discussion  of 
the  following  subjects. 

1.  Paravaginal  hysterectomy. 

2.  Radical  abdominal  hysterectomy. 

3.  Ignihysterectomy. 

1.  Paravaginal  Hysterectomy. — Paravaginal  hysterectomy,  known  as 
Schuchardt's^  operation,  especially  adapted  to  cervical  carcinoma,  is  the 
most  radical  of  all  vaginal  operations,  and  is  performed  as  follows:- 

With  the  forefinger  and  the  thumb  of  the  left  hand  the  operator 
seizes  the  posterior  portion  of  the  left  labium,  while  an  assistant  seizes 
the  parts  in  the  middle  line  and  puts  them  on  the  stretch.  The  operator 
then  makes  an  incision  between  the  two  sets  of  fingers,  and,  so  far  as 
possible,  divides  at  one  stroke  in  a  forward  direction  the  vaginal  wall 
up  to  the  left  side  of  its  insertion  into  the  cervix  uteri  and  downward 
and  backward  to  the  middle  of  the  coccygeal  region.  By  this  incision 
he  splits  the  whole  vaginal  tube,  the  left  labium,  the  paravaginal  and 

•  The  reader  is  referred  to  a  masterly  paper  read  before  the  American  Gynecological  Society  at 
Niagara  Falls,  1905,  in  which  George  Gellhom,  of  St.  Louis,  discussed  fully  the  various  radical  opera- 
tions, with  special  reference  to  paravaginal  hysterectomy. 

-  Adaptation  from  Gellhorn,  Trans.  Amer.  Gyn.  Soc,  1905. 


414  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

pararectal  tissues,  the  levator  ani  muscle,  the  coccygeal  muscles,  the 
cellular  tissue  of  the  ischiorectal  fossa,  as  well  as  the  skin  of  the  peri- 
neum and  of  the  lateral  anal  region  down  to  the  sacrum.  The  wound 
in  the  pararectal  tissue  is  carried  to  the  left  only  far  enough  to  avoid 
the  rectum  and  sphincter  ani  muscle — that  is,  about  a  finger's  breadth 
from  the  middle  line.  The  incision  on  the  left  side  is  more  convenient 
for  the  right-handed  operator,  but  when  a  portion  of  cancerous  rectum 
must  be  removed  with  the  cancerous  vaginal  wall,  bilateral  incisions 
become  necessary. 

After  controlling  the  copious  venous  hemorrhage  the  surgeon  catches 
the  vagina  as  far  as  possible  away  from  the  cancer  with  vulsella,  and 
below  these  vulsella  makes  a  circular  incision  through  the  vagina,  con- 
necting at  right  angles  with  the  paravaginal  cut;  he  now  separates  the 
vagina  by  blunt  dissection  in  an  upward  direction  and  sews  the  cuff 
thus  formed  over  the  portio  vaginalis  in  order  to  protect  the  field  of 
operation  from  uterine  secretions,  the  sutures  being  left  long  to  serve 
as  guides  in  the  following  steps  of  the  operation. 

The  effect  of  this  paravaginal  incision  is  surprising.  In  place  of  a 
vaginal  tube  we  have  before  us  a  shallow  excavation  about  an  inch 
deep,  at  the  bottom  of  which  the  parametria  are  seen  in  full  extent 
and  within  easy  reach. 

The  operator  now  separates  the  bladder  in  front,  partly  by  scissors, 
partly  by  blunt  dissection,  clear  to  the  pelvic  cavity,  and  in  the  same 
manner  opens  into  Douglas'  space  behind;  then  passing  the  left  fore- 
finger successively  behind  each  parametrium,  he  draws  it  within  easy 
reach  and  ligates  it,  together  with  its  broad  ligament,  as  far  from  the 
uterus  as  possible,  with  strong  catgut,  and  excises  the  uterus,  together 
with  the  adjacent  parametrium  on  each  side  of  it. 

In  the  removal  of  considerable  portions  of  the  parametria  the  regions 
of  the  ureters  are  invaded  and  the  ureters  themselves  may  have  to  be 
laid  bare.  Dissections  in  these  parts  involve  great  technical  difficulties, 
and  should  be  undertaken  only  by  specially  expert  surgeons.  In  this 
connection  the  reader  is  referred  to  the  original  literature,  especially 
papers  by  Schuchardt,^  Schuata,^  Kroemer,^  Kundrat,^  Bovee,^  and 
Mackenrodt.^ 

The  suggestion  of  Clark  to  make  the  operation  with  catheters  pre- 
viously passed  into  the  ureters  is  most  practical.  The  vaginal  portion 
of  the  wound  is  closed  loosely  by  catgut,  in  such  a  way  as  to  unite  the 
anterior  to  the  posterior  peritoneal  edges  and  to  draw  into  it  the  cut  ends 

1  K.  Sohuchardt.     Centralblatt  f.  Chirurgie,  1893,  No.  51. 

K.  Schuchardt.  Ueber  die  paravaginale  Methode  der  Extirpatio  uteri  und  ihre  Heilerfolge  beim 
Uteruslcrebs.     Monatssciirift  f.  Geb.  u.  Gyn.,  1901,  vol.  xiii. 

K.  Schuchardt.     Transactions  of  the  German  Gynecological  Congress,   1901. 

2  F.  Schauta.  Die  Operation  des  Gebaermutterkrebses  mittelst  des  Schuchardt'schen  Paravaginal- 
schnittes.     Monatsschrift  f.  Geb.  u.  Gyn.,  1902,  vol.  xv. 

F.  Schauta.  Die  Berechtigung  der  vaginalen  Totalexstirpation  bei  Gebaermutterkrebs.  Monats- 
schrift f.  Geb.  u.  Gyn.,  190-1,  vol.  xix. 

3  P.  Kroemer.     Die  Lymphorgane  der  weib.  Genitalien,  etc.    Archiv  f.  Gyn.,  1904,  vol.  Ixxiii. 

■•  R.  Kundrat.  Ueber  die  Ausbreitung  des  Carcinoms  in  parametranen  Gewebe  bei  Krebs  des 
CoUum  Uteri.       Archiv  f.  Gyn.,  vol.  Ixix,  Heft  2. 

•■i  J.  W.  Bov6e.  The  Treatment  of  Cancer  of  the  Cervix  Uteri  in  Advanced  Stages.  American 
Medicine,  .January  7,  1905. 

s  A.  Mackenrodt,  Zentralblatt  f.  Gyn.,  1905,  No.  11. 


TUMORS  OF  THE   UTERUS  415 

of  the  broad  li*j;aments.  The  cutaneous  portion  is  closed  more  firmly, 
as  in  perineorrhaphy.  A  gauze  drain,  according  to  the  special  indica- 
tion, may  or  may  not  be  indicated.     Union  by  first  intention  is  usual. 

The  advantages  claimed  for  this  most  radical  of  all  vaginal  opera- 
tions are  less  immediate  danger  to  life,  in  comparison  Avith  radical 
abdominal  operations,  and  greater  freedom  from  recurrence,  in  com- 
parison with  the  ordinary  vaginal  operations.  The  relative  value  of 
Schuchardt's  operation  will  be  considered  later. 

2.  Radical  Abdominal  Hysterectomy. — The  development  of  this  opera- 
tion in  its  various  phases  is  inseparably  connected  with  the  labors  of 
H.  W;  Freund,  Rumpf,  von  Rosthorn,  Ries,  Schauta,  Clark,  Cullen, 
Werder,  Russell,  Wertheim,  and  others. 

After  preliminary  curettage  and  cauterization  of  exposed  surfaces 
in  the  vagina  and  after  thorough  disinfection  of  the  vaginal  and  ab- 
dominal fields  of  incision,  the  ureters,  according  to  Clark,  should  be 
catheterized,  and  the  catheters  left  in  them  as  guides  by  which  the 
ureters  may  be  avoided  during  the  operation. 

The  patient  being  in  the  Trendelenburg  position,  the  abdomen  is 
opened  between  the  symphysis  pubis  and  umbilicus  and  the  lumbar, 
iliac,  and  sacral  glands,  the  pelvic  ligaments,  and  the  parametria  are 
examined  for  more  accurate  diagnosis  of  the  disease.  Wertheim,  Ries, 
and  others  advocate  the  removal  of  glands  with  varying  degrees  of 
thoroughness  in  connection  with  the  radical  operation.  Others,  notably 
Clark  and  Schauta,  take  the  reasonable  ground  that  in  very  many 
cases  the  glands  are  not  involved,  and  that  in  all  cases  the  removal  of 
them  so  far  increases  the  primary  danger  of  operation  as  to  outbalance 
any  possible  freedom  from  recurrence.  The  removal  of  glands  may 
be  disregarded,  and  for  purposes  of  this  description  it  is  so  decided. 

"Special  stress,"  as  Clark^  wisely  says,  "should  be  laid  upon  the 
necessity  of  this  preliminary  survey,  for,  as  the  question  must  now  be 
viewed,  it  is  useless  to  perform  more  than  a  simple  abdominal  opera- 
tion if  the  higher  groups  of  glands  are  involved,  for  in  such  cases  we 
can  only  hope  for  a  palliative  effect  from  any  operation.  If,  on  the 
other  hand,  preliminary  examination  of  the  pelvic  structures  has  been 
negative  so  far  as  metastasis  or  wide  intraligamentary  extension  is 
concerned,  the  scope  of  the  local  operation  becomes  radical." 

The  operation  now  will  be  continued  as  follows  r^  The  intestines 
are  packed  well  back  into  the  abdominal  cavity  with  gauze  bolsters, 
wrung  out  of  hot  salt  solution.  Painstaking  care  in  this  step  renders 
the  operation  very  much  easier  and  guards  against  post-operative 
complications.  The  fundus  is  grasped  by  a  heavy  tenaculum  forceps, 
and  forcibly  drawn  upward  to  the  opposite  side  from  that  upon  which 
the  operation  is  to  begin.  The  peritoneum  is  snipped  open,  as  suggested 
by  Wertheim,  beginning  over  the  bifurcation  of  the  common  iliac 
artery  and  continuing  down  into  the  pelvis  to  the  point  where  the 
ureters  enter  the  bladder.  The  infundibulopelvic  ligaments  at  the  pelvic 
brim  are  next  ligated  doubly  and  cut  between  the  ligatures. 

1  Kelh'-Xoble.  vol.  i,  p.  737.  -  .\daptation  from  Clark.     Kelly-Xoble,  vol.  i,  pp.  738-744. 


416  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

The  round  ligament  is  separately  ligated  one  inch  from  the  cornu 
uteri  and  divided.  The  peritoneal  incision  is  now  carried  around  in 
front  of  the  uterus,  through  the  uterovesical  reflection  to  the  opposite 
side.  The  bladder  is  detached  from  the  uterus  with  sponge  pressure, 
the  uterus  being  sharply  drawn  upward  into  the  abdomen.  Detach- 
ment of  the  bladder  from  the  cervix  being  completed,  and  the  dis- 
section carried  well  down  into  the  paravaginal  tissues.  In  this  way 
the  vagina  is  detached  from  its  fixed  points  and  appears  as  an  isolated 
sheath.  If  the  bougies  are  in  place,  or  if  the  anatomical  guides  are  well 
in  mind,  the  ureters  can  most  easily  be  located  at  the  brim  of  the 
pelvis  where  they  cross  over  the  external  iliac  vessels.  From  this  point 
they  are  traced  downward  to  the  points  where  they  swing  inward  to 
enter  the  bladder.  With  the  ureters  isolated  and  pushed  out  of  the 
way,  the  ligation  of  the  uterine  vessels  becomes  a  relatively  safe  pro- 
cedure. The  vessels  lifted  up  on  the  tip  of  the  index-finger  are  doubly 
ligated  well  out  against  the  pelvic  wall.  The  ligature  is  best  applied 
with  a  curved  aneurysmal  ligature  carrier.  This  step  having  been 
duplicated  on  the  opposite  side,  the  chief  danger  of  hemorrhage  and 
of  injury  to  the  ureters  is  largely  overcome. 

The  broad  ligaments  are  now  cut  away  from  their  pelvic  attach- 
ments, leaving  the  uterus,  its  appendages,  and  the  upper  portion  of 
the  vagina  held  in  the  pelvis  by  the  uterosacral  ligaments.  The  uterus 
is  now  pulled  upward  and  forward  against  the  symphysis  pubis  to 
facilitate  the  division  of  the  recto-uterine  reflection  of  peritoneum  and 
the  uterosacral  ligaments.  The  peritoneum  should  be  opened  well 
back  of  the  cervix.  The  uterosacral  ligaments  are  ligated  or  clamped 
and  divided  as  close  to  their  sacral  attachments  as  possible.  Small 
bleeding  vessels  may  be  clamped  and  subsequently  ligated. 

Up  to  this  point  the  operation  has  followed  the  general  plan  of  all 
radical  operations,  but  here  the  best  suggestion  which  Wertheim  has 
offered  becomes  imperative.  Instead  of  using  imbricated  ligatures 
around  the  circumference  of  the  vagina,  Wertheim  has  employed  right- 
angled  clamps  with  which  to  compress  the  walls  of  the  vagina  from 
above  while  the  uterus  is  excised.  With  traction  forceps  the  uterus  is 
pulled  as  high  as  possible  into  the  abdomen,  thus  bringing  a  consider- 
able portion  of  the  vagina  into  view.  Two  clamps  are  applied  to  the  iso- 
lated vaginal  tube,  one  on  one  side  and  the  other  on  the  opposite  side 
and  overlapping  the  first.  These  clamps  are  quickly  placed  and  permit 
the  immediate  excision  of  the  uterus  with  the  upper  portion  of  the 
vagina.  In  the  separation  of  the  pelvic  attachments  of  the  uterus, 
and  in  cutting  through  the  vagina,  the  cautery  should  invariably  be 
employed,  and  after  the  excision  of  these  structures  the  surrounding 
tissues,  with  due  protection  to  the  ureter,  bladder,  and  rectum,  should 
be  thoroughly  burned.  While  he  believes  the  ligature  should  never 
be  discarded,  he  recognizes  without  reservation  the  splendid  value  of  the 
cautery  in  excising  cancerous  tissue.  By  the  cautery  method  adjacent 
tissue  which  might  escape  the  knife  is  removed.  Extirpation  being 
completed,  the  vagina  is  closed  below  the  clamps,  with  either  a  running 


TUMORS  OF   THE   UTERUS  417 

or  an  interrupted  catgut  suture,  and  tlie  clamps  are  removed.  If  a 
gauze  drain  is  emi)l()yed,  a  small  opening  is  left,  through  which  the 
gauze  projects  into  the  vagina,  from  which  it  can  he  rcmoxed  two  days 
later.  The  vesical  and  rectal  reflections  of  the  peritoneum  are  brought 
together  with  a  running  catgut  suture.  The  abdomen  is  closed  with- 
out drain  in  the  usual  manner. 

3.  Ignihysterectomy. — The  great  difficulty,  tediousness,  and  excessive 
mortality  of  the  operation  just  described  to  some  extent  outbalance 
any  possible  increase  of  permanent  cures  due  to  it — a  fact  that  maj-  to 
a  greater  and  greater  extent  limit  the  u.se  of  hemorrhagica!  incisions 
and  ligatures,  and  in  place  of  them  substitute  the  bloodless  and  immedi- 
ately safer  method  of  igniextirpation.  Indeed,  the  foregoing  flescrip- 
tion  of  technique  of  radical  abdominal  hysterectomy  includes  somewhat 
extensive  use  of  the  thermocautery  and  thereby  emphasizes  the  growing 
tendency  of  the  radical  operator  to  recognize  the  paramount  value  of 
this  agent. 

Igniextirpation  of  the  entire  uterus,  with  adjacent  tissues,  has  been 
developed  by  X.  O.  Werder,^  of  Pittsburg.  The  technique  of  his 
operation,  substantially  as  set  forth  by  himself,  is  as  follows: 

1.  Thorough  curettage  of  the  cancerous  surfaces  in  the  vagina  and 
control  of  resulting  hemorrhage  by  actual  cauterization. 

2.  An  incision  entirely  around  the  cervix  as  far  as  practicable  from 
the  affected  area  by  means  of  the  cautery  knife  at  a  dull  heat,  which 
prevents  oozing  and  renders  the  wound  dry.  This  incision  is  made 
while  the  uterus  is  drawn  well  down  toward  the  vulva,  and  the  vaginal 
walls  protected  from  the  hot  knife  by  means  of  retractors.  Dissection 
by  the  cautery  knife  is  continued  anteriorly  between  the  bladder  and 
uterus,  the  bladder  being  drawn  firmly  away  from  the  uterus  by  means 
of  a  retractor  until  the  peritoneum  is  reached  but  not  opened.  The 
cul-de-sac  of  Douglas  is  then  entered  by  similar  careful  dissection, 
guided  by  the  index-finger.  The  lateral  vaginal  attachments  are  then 
burned  through.  The  vaginal  wound  is  carefully  inspected  now  and 
all  surfaces  not  thoroughly  blackened  and  charred  are  gone  over  again 
by  the  dome-shaped  cautery  until  thoroughly  charred.  The  vagina 
is  now  packed  lightly  with  gauze. 

3.  The  abdomen  having  been  prepared  for  laparotomy,  a  median 
incision  is  made  between  the  symphysis  and  umbilicus,  and  the  uterus 
seized  and  drawn  into  the  opening  by  means  of  vulsellum  forceps  and 
carefully  packed  oflF  from  the  surrounding  peritoneal  cavity  by  means 
of  sponge  pads. 

4.  The  bladder  peritoneum  at  the  vesical  reflexion  is  now  dissected 
off  from  side  to  side  by  means  of  the  hot  knife,  and  the  anterior 
vaginal  pouch  is  opened  so  as  to  expose  the  vaginal  gauze  packing. 
A  Downs'  electrothermic  cautery  is  then  applied  to  the  right  infun- 
dibulopelvic  ligament  and  round  ligament,  the  surrounding  parts 
being  carefully  protected  by  the  shield  and  by  additional  pads.     The 

1  Werder,  X.  O.     Surgery,  Gynecology,  and  Obstetrics,  Januan,',  1907. 


418  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

tissues  included  in  the  clamp  are  then  thoroughly  treated  by  the  gal- 
vanic heat  until  they  appear  as  a  thin  white,  horny  ribbon.  The  clamp 
is  then  removed  and  this  ribbon  is  cut  through  at  its  inner  margin, 
and  if  free  from  bleeding  is  dropped.  The  other  side  is  treated  in  the 
same  way. 

5.  The  parametrium  is  seized  on  the  least  affected  side  with  the  cau- 
tery clamp  and  burned  through,  the  bladder  and  ureter  being  care- 
fully avoided.  The  horny  ribbon  thus  formed  is  cut  through  and  the 
remaining  portion  of  the  broad  ligament  and  uterosacral  ligament  are 
treated  in  the  same  manner  and  dropped.  One  side  of  the  uterus  now 
being  freed  from  all  its  attachments,  the  same  treatment  is  repeated 
on  the  other  side.  If  the  technique  has  been  good,  the  cauterized 
surfaces  will  be  dry,  no  blood  except  from  the  preliminary  cauteriza- 
tion having  been  lost. 

6.  The  stump  of  the  vagina  now  exposed  is  closed  by  means  of  a 
running  catgut  suture,  the  bladder  is  brought  over  the  sutured  vaginal 
stump,  and  its  peritoneum  sutured  to  the  rectum.  Adjacent  peritoneum 
is  now  stitched  over  each  broad  ligament  stump. 

7.  The  entire  field  of  operation  now  being  covered  and  protected 
against  infection  by  peritoneum,  and  having  no  exposed  surfaces,  the 
abdomen  is  closed  without  drain  in  the  usual  manner. 

History  and  Rationale  of  Igniextir potion. — Werder  has  based  his 
operation  upon  the  principles  of  the  well-known  Byrne  operation  of 
amputation  of  the  cervix  by  the  galvanocautery,  extending  it  to  com- 
plete hysterectomy.  The  statistics  of  Byrne^  are  a  matter  of  history. 
They  show  369  cases  of  cervical  cancer  removed  by  galvanocautery, 
with  no  primary  mortality,  and  19  per  cent,  of  permanent  cures — a 
very  remarkable  result,  even  allowing  for  some  possible  errors  of  diag- 
nosis which  may  have  led  to  the  inclusion  of  a  few  cases  in  which  the 
presence  of  undeniable  cancer  remains  unproved. 

"Byrne  in  all  his  writings  on  this  subject  emphasizes  the  impor- 
tance of  thorough  and  repeated  cauterizations  of  the  wound  surfaces 
and  edges  from  which  cancerous  material  has  been  removed,  regarding 
it  as  the  best  safeguard  against  the  recurrence  of  the  disease."  He  thinks 
that  "there  is  hardly  any  doubt  that  the  developmental  activity  of 
the  cancer  cells  and  germs,  in  certain  stages  and  under  certain  con- 
ditions, may  be  arrested  or  permanently  destroyed  by  a  degree  of  heat 
much  below  that  which  would  be  detrimental  or  destructive  to  normal 
tissues;"  he  is  certain  that  "the  thermal  agent  exerts  some  strong 
modifying  influence  on  pathological  processes  much  deeper  than  the 
surface  actually  cauterized,  hence  the  importance  of  repeated  appli- 
cations, so  that  every  spot  suspected  of  contamination  may  be 
thoroughly  charred." 

Byrne's  results,  especially  the  freedom  from  local  recurrences,  would 
seem  to  justify  the  above  conclusions.  The  most  remarkable  feature 
of    this   operation,  when   compared   to   other  operative  measures,  is 

1  Transactions  of  the  American  Gynecological  Society,  1889,  vol.  xiv;  same,  188. 


TUMORS  OF   THE   UTERUS  419 

unquestionably  the  absence  of  vaginal  recurrences.  Byrne  says :  "  I  have 
never  known  an  instance  of  rehipse  in  which  the  disease  has  returned 
to  the  part  from  which  it  had  oriii,inally  l)een  excised.  1  have  repeatedly 
observed  the  reapi)earance  in  the  fun(kis,  ovaries,  and  some  of  the 
atljacent  tissues,  but  1  have  never  known  a  single  instance  in  which 
the  disease  has  reappeared  on  or  very  close  to  the  cauterized  surface 
from  which  the  cervix  had  been  removed  by  galvanocautery."  This 
same  innnunity  from  local  recurrences  is  claimed  by  other  operators 
using  the  galvanocautery,  such  as  Pawlick,  Madden,  and  others,  so 
that  Byrne's  experience  seems  by  no  means  singular.  The  facts  appar- 
ently bear  out  Byrne's  assertion  that  the  influence  of  the  cautery 
extends  be\'ond  the  actual  field  of  operation,  carrying  destruction  to 
cancerous  elements  deep  into  the  tissues,  and,  therefore,  doing  much 
more  radical  work  than  can  be  accomplished  by  the  use  of  the  knife 
or  scissors  under  similar  conditions. 

Byrne's  experience  covers  367  cases,  extending  over  a  period  of 
twenty  years,  without  a  single  operative  death;  140  of  these  were 
carcinoma  of  the  cervix;  in  219  cases  both  cervix  and  body  were  in- 
volved, and  in  only  8  cases  was  the  disease  confined  to  the  corpus 
uteri;  151  cases  were  lost  sight  of  during  the  first  year;  there  remained, 
therefore,  216  cases  of  which  the  subsequent  history  is  known.  Of 
these,  19  remained  free  from  the  disease  from  ten  to  eighteen  years, 
22  for  five  years  or  more,  and  93  for  two  years  or  more.  Thus  19  per 
cent,  were  free  from  recurrence  for  five  years  or  more,  and  over  43 
per  cent,  for  two  years  and  over.^ 

The  advantages  of  this  operation  are  numerous  and  forceful;  they 
are: 

a.  Comparative  simplicity  of  technique. 

h.  Comparative  freedom  from  post-operative  infection. 

c.  Comparative  freedom  from  hemorrhage;  most  important  in  view 
of  the  fact  that  cancerous  patients  are  anemic. 

d.  Surprisingly  low  percentage  of  immediate  mortality,  considering 
the  radical  nature  of  the  operation. 

e.  A  most  encouraging  percentage  of  permanent  cures,  especially 
when  due  allow^ance  has  been  made  for  the  much  greater  immediate 
mortality  of  paravaginal  hysterectomy  and  radical  abdominal  hyster- 
ectomy by  the  methods  of  Schuchardt,  Wertheim,  and  others. 

Immediate  Mortality  of  Hysterectomy  for  Carcinoma. — The  mortality 
depends  upon  the  character  of  the  operation.  Schuchardt's  operation 
will  show  a  mortality  of  at  least  10  per  cent.  The  radical  vaginal 
operation  in  the  hands  of  expert  operators  will  show  an  immediate 
mortality  of  from  10  to  20  per  cent.  The  mortality  with  improved 
technique  probably  cannot  be  reduced  below  10  per  cent.  The  ordinary 
vaginal  hysterectomy,  as  described  in  Chapter  XX.,  for  pelvic  inflam- 
mation, in  properly  selected  cases  shows  in  expert  hands  not  o\'er 
1  per  cent,  of  immediate  mortality.  Ignihysterectomy  as  performed 
by  Werder  is  almost  as  safe. 

1  Quoted  from  Werder,  Kelly-Noble,  vol.  i. 


420  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Recurrence  of  Carcinoma  after  Hysterectomy, — Early  diagnosis  must  he 
urged  as  a  7iecessary  factor  in  the  successful  surgical  treatment  of  cancer 
of  the  uterus.  The  recurrence  of  cancer  after  hysterectomy  is  less 
frequent  than  after  the  removal  of  cancer  from  other  parts  of  the  body. 
Even  in  cancer  of  the  breast,  where  by  reason  of  the  exposed  position 
of  the  growth  the  diagnosis  usually  is  made  earlier  than  in  the  uterus, 
recurrence  is  much  more  frequent.  This  is  true  notwithstanding  the 
common  practice  of  thorough  attempt  at  removal  of  the  subclavian 
and  axillary  glands  in  connection  with  breast  operations,  and  notwith- 
standing the  fact  that  in  the  usual  hysterectomy  the  parametric  glands 
seldom  are  removed.  The  statistics  of  the  best  operators  show  freedom 
from  the  disease  two  or  more  years  after  vaginal  hysterectomy  by  the 
ordinary  method,  as  described  in  Chapter  XX.,  in  a  very  appreciable 
number  of  cases.  The  percentage,  however,  of  yermanent  cures  is  much 
greater  for  corporeal  than  for  cervical  cancer. 

Schuchardt's  operation,  which  if  thoroughly  performed  will,  perhaps, 
show  almost  as  high  an  immediate  mortality  as  the  radical  abdominal 
operation  without  removal  of  the  glands,  will  be  followed,  doubtless, 
by  a  somewhat  larger  percentage  of  recurrences.  It  is  more  than  pos- 
sible that  ignihysterectomy,  which  of  all  radical  operations  has  much 
the  least  primary  mortality,  will  give  almost  if  not  quite  as  much  free- 
dom from  recurrence  as  can  be  accomplished  by  either  of  the  other 
radical  operations. 

The  Operation  of  Election. — In  our  present  unsatisfactory  state  of 
knowledge  we  may  summarize  as  follows:  1.  The  removal  of  glands 
is  extra-hazardous  and  involves  an  immediate  mortality  which  may 
more  than  offset  any  probable  advantage.  The  difficulty  and  danger 
of  removal  of  all  the  lymphatic  glands  in  connection  with  hysterectomy  will 
be  apparent  from  examination  of  the  frontispiece;  moreover,  removal 
of  the  lymph-vessels,  through  which  carcinoma  must  travel  to  reach 
the  glands,  is  impossible;  therefore,  if  cancer  has  passed  far  beyond  the 
uterus,  removal  of  glands  is  of  doubtful  value.  2.  If  the  parametria,  and 
especially  the  glands,  are  demonstrably  affected,  a  palliative  opera- 
tion only  should  be  elected.  3.  If  the  parametria  and  glands  are  not 
demonstrably  affected,  and,  therefore,  a  radical  operation  gives  hope 
of  permanent  cure,  the  choice  will  be  between  radical  abdominal  opera- 
tion without  removal  of  glands,  on  the  one  hand,  and  ignihysterectomy 
on  the  other.  The  latter  procedure,  in  consideration  of  its  lesser 
immediate  mortality,  and  its  encouraging  freedom  from  recurrence, 
would  appear,  for  the  present  at  least,  to  offer  advantages  both  from 
the  conservative  and  from  the  radical  points  of  view.  Radical  abdominal 
hysterectomy  could  not  remove  the  parametria  and  broad  ligaments 
much  more  than  half  an  inch  nearer  to  the  pelvic  walls  than  ignihyster- 
ectomy. This  increased  removal  would  hardly  offset  the  additional 
mortality  of  the  former  operation.  Besides,  the  effect  of  the  cautery 
may  be  destructive  to  cancer  far  beyond  the  charred  section. 

Unfortunately,  the  onset  of  cancer  of  the  uterus  is  so  insidious  that 
early  symptoms — hemorrhage  and  watery  discharge — often  are  over- 


TUMORS  OF  THE   UTERUS  421 

looked  or  attributed  to  other  causes;  hence,  the  diagnosis  usually  is 
not  made  until  too  late  for  permanent  cure  by  radical  hysterectomy. 
In  later  stages,  when  the  cancer  has  extended  to  the  bladder  or  rectum, 
or  has  involved  demonstrably  the  parametria,  or  glands,  and  especially 
when  the  uterus  is  fixed  in  carcinomatous  infiltrate,  with  thickening 
of  the  broad  ligaments,  simple  vaginal  hysterectomy  as  described  in 
Chapter  XX.  is  permissible  only  as  a  palliative  measure  and  is  of 
questionable  value. 

Palliative  Treatment 

The  purpose  of  palliative  treatment  is  to  check  the  exhaustive  hemor- 
rhages and  discharges.  This  may  be  accomplished  by  sharp  curettage 
of  the  more  superficial,  soft,  ulcerating  portion  of  the  cancerous  growth. 
Remember  that  the  disease  in  advanced  cases  may  have  extended 
through  vesical,  rectal,  or  uterine  walls,  and  that  without  care  the 
bladder,  bowel,  or  peritoneum  may  be  opened.  The  redundant  can- 
cerous mass  having  been  removed  by  the  curette,  the  bleeding  surfaces, 
that  is,  the  exposed  surfaces,  should  be  charred  over  with  the  Paquelin 
or  galvanic  cautery. 

The  cancerous  growth  may  be  kept  down  and  the  fetid,  discharges 
at  the  same  time  deodorized  by  the  application,  every  three  or  four 
days,  of  a  saturated  solution  of  iodine  crystals  in  pure  carbolic  acid. 
This  application  is  made  best  on  small  tampons.  The  healthy  parts 
of  the  vagina  may  be  protected  by  covering  the  adjacent  mucosa  with 
gauze  pads  during  the  application  of  the  solution. 

Deodorizing  douches  are  useful  to  destroy  the  nauseating  fetor  of 
discharges.  Among  the  best  of  these  are  peroxide  of  hydrogen  and 
2  per  cent,  solution  of  potassium  permanganate.  Profuse  hemorrhage 
may  be  checked  by  a  douche  of  hot  water,  hot  vinegar,  or  hot  alum 
solution.  Should  the  vaginal  tampon  be  used,  it  will  become  intoler- 
ably offensive,  and  therefore  should  be  removed  every  twenty-four 
hours.  Erosions  and  excoriations  of  the  external  genitals  and  nates, 
which  are  caused  by  the  ichorous  discharges  from  above,  may  be 
palliated  by  frequent  bathing  and  by  the  application  of  benzoated 
zinc  oxide  ointment. 

The  .r-ray  and  radium  in  the  hands  of  an  expert  are  known  in  a 
limited  percentage  of  cases  to  retard — even  to  check  the  growth  for 
considerable  periods  of  time  and  very  exceptionally  have  been  reported 
to  have  effected  radical  cure.  The  use  of  them  therefore  is  urged  as  a 
palliative  measure  in  inoperable  cases  and  as  a  hopeful  resource  against 
recurrence  after  hysterectomy. 

The  general  treatment  includes  regulation  of  the  bowels  and  kidneys, 
tonics,  nutritious  food,  and  mild  exercise.  Pain  is  a  clear  indication 
for  morphine  or  opium  in  quantity  sufficient  to  give  relief.  Life  will 
be  limited  to  a  few  months;  hence  the  danger  of  the  opium  habit  is 
not  significant.  Numerous  drugs,  both  for  local  and  systemic  use, 
have  been  lauded  as  cancer  cures;  they  are,  so  far  as  their  merits  have 
been  investigated,  useless. 


CHAPTER  XXVI 
TUMORS  OF  THE  UTERUS 

SARCOMA 

Sarcoma  is  a  malignant  tumor  belonging  to  the  connective-tissue 
group,  and,  as  compared  with  carcinoma,  is  of  rare  occurrence;  it  is 
more  apt  to  occur  during  the  period  of  sexual  maturity,  but  has  been 
observed  in  the  periods  of  infancy,  childhood,  youth,  and  senility. 

Etiology  of  Sarcoma 

The  causes  of  sarcoma  are  unknown. 

Pathology  of  Sarcoma 

Sarcoma  may  develop  from  any  of  the  following  sources : 

The  interglandular  connective  tissue  of  the  endometrium. 

The  intermuscular  connective  tissue  of  the  myometrium. 

The  walls  of  the  blood-vessels. 

The  perivascular  connective  tissue. 

The  muscle  cells. ^ 

Any  of  the  structures  of  a  uterine  myoma. 
Sarcoma  may  be  divided  histologically  into: 

Small  round-cell  sarcoma. 

Large  round-cell  sarcoma. 

Spindle-cell  sarcoma. 
Sarcoma  may  be  divided  regionally  into: 

Sarcoma  of  the  uterine  mucosa. 

Sarcoma  of  the  entire  uterus — diffuse  sarcoma. 
The  tendency  of  sarcoma  is  to  scatter  its  nodules  through  the  uterine 
walls,  to  penetrate  the  blood-vessels,  to  extend  to  the  peritoneum, 
and  to  involve  adjacent  organs.  The  thickened,  enlarged  uterus,  the 
bladder,  and  the  neighboring  intestines  then  are  matted  together  in 
the  sarcomatous  disease  and  materially  increase  the  size  of  the  tumor. 
The  disease  also  is  prone  to  transmit  emboli  by  the  veinous  route  to 
the  lungs,  liver,  kidney,  spleen,  and  brain.  These  and  other  organs 
now  may  become  rapidly  involved  in  metastatic  sarcoma.  It  is  a 
peculiarity  of  the  disease  that  emboli  pass  through  the  veins  to  dis- 
tant organs.  In  this  respect  it  differs  from  carcinoma,  which  is  apt  to 
travel  by  the  lymphatics  and  to  be  arrested  by  thrombic  plugging  at 
points  much  nearer  to  the  original  seat  of  the  disease. 

Sarcoma,  especially  when  it  has  developed  from  myoma,  may  have 
many  of  the  gross  characteristics  of  myoma — that  is,  it  may  be  sub- 

1  Whitridge  Williams.     American  Journal  of  Obstetrics.  1894,  vol.  xxix. 
(  422  ) 


PLATE    XVIII 


Sarcoma  of  the  Body  of  the  Uterus. 


PLATE    XIX 


FIGURE  1 


FIGURE  2 


^S?T^  e^D^T^^  /v'-V-^  ^rA^yi^vi 


FIGURE  8 


'«W8.»'fl>9&i 


^i 


TUMORS  OF  THE  UTERUS  423 

mucous,  subserous,  intramural,  round,  oblong,  irregular,  multinodular, 
soft,  hard,  circumscribed,  or  diti'use.  The  older  pathologists  designated 
these  growths  as  "  recitrring  fibroids;''  they  sometimes  are  called /6ro- 
sarcomata  or  interstitial  sarcomata.  They  rarely  are  encapsulated, 
though  usually  well  defined.  The  cells  are  round  or  spindle;  in  the  latter 
forms  the  spindle  cells  often  are  so  elongated  as  to  appear  like  fibrous 
tissue,  hence  the  name  fibrosarcoma.  Diffuse  sarcoma  usuall\-  develops 
from  the  interglandular  connective  tissue  of  the  endometrium.  In 
this  form  the  small  round  cell  usually  predominates  over  the  spindle 
cell.  The  growth  may  be  confined  to  separate  areas,  or  may  infiltrate 
the  whole  endometrium  and  rapidly  involve  the  entire  uterus  and  adja- 
cent organs.  It  develo])s  both  in  the  endometrium  and  in  the  muscularis. 
Intra-uterine  sarcoma  may  take  the  form  of  numerous  soft  medullary 
polypi.  When  removed  by  the  curette,  they  have  the  gross  appearance 
of  carcinoma,  and  microscopically  the  small  round  cells  of  sarcoma  may 
be  difficult  to  distinguish  from  the  round  cells  of  inflammation  in 
endometritis. 

There  is  a  form  of  sarcoma  which  in  gross  appearance  resembles 
grape-like  bodies,  and  sometimes  is  called  hutyroides;  it  is  extremely 
rare,  usually  originates  in  the  cervix  uteri,  and  has  the  form  of  cyst- 
like masses  resembling  hydatid  moles.  This  growth  is  composed  mostly 
of  round  and  spindle  cells;  it  has  been  observed  in  the  uteri  of  adult 
women  and  children,  and  in  the  vaginae  of  children. ^  The  development 
is  most  rapid  and  malignant. 

All  sarcomata,  especially  the  diffuse,  are  extremely  vascular.  The 
blood-vessels  sometimes  are  dilated  so  enormously  as  to  form  cavern- 
ous spaces.    The  lymph-spaces  may  dilate  into  cystic  cavities. 

Diagnosis  and  Prognosis  of  Sarcoma  of  the  Uterus 

The  symptoms  and  course  vary  with  different  forms  of  sarcoma. 

The  interstitial  spindle-cell  sarcoma,  formerly  called  recurring  fibroid, 
is  sometimes  of  slow  gro^'th.  In  exceptional  cases  it  may  not  destroy 
life  for  several  years. 

The  diffuse,  small  round-cell  sarcoma,  on  the  contrary,  is  ordinarily 
much  more  malignant  than  carcinoma;  it  often  goes  on  to  a  fatal 
result  in  a  few  months.  The  small  round-cell  sarcoma  is  most  malig- 
nant, the  large  round-cell  less  malignant,  and  the  spindle-cell  least 
malignant. 

'  Peck.     From  Playfair's  System  of  Gynecology. 

Explanation'  of  Plate  XIX 

FiGCRE  1. — Small  round-cell  sarcoma.  Observe  that  the  vessels  are  mere  blood-spaces  for  the 
most  part  destitute  of  walls,  that  the  cells  are  composed  almost  entirely  of  nuclei,  and  that  they  are 
of  the  same  size  as  the  red  blood-corpuscles.  Muscular  elements  are  invaded  and  mostly  destroyed 
by  sarcoma.     2.50  diameters. 

Figure  2. — Targe  round-cell  sarcoma.  The  nuclei  occupy  almost  the  entire  cells.  The  blood- 
spaces  have  no  walls.  The  cells  are  five  or  six  times  as  large  as  the  red  blood-corpuscles.  The  sarcoma 
has  invaded  and  nearly  destroyed  the  muscular  tissue,  the  remainder  of  which  is  shown  in  the  form 
of  wa\nng  fibrous-like  tissue  running  irregularlv  across  the  field.     2.50  diameters. 

Figure  3. — Small  spindle-cell  sarcoma.  Cells  mostly  composed  of  nuclei  about  twice  as  lar^e  as 
the  red  blood-corpuscles.    Blood-spaces  have  no  walls.    250  diameters. 


424  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

The  symptoms  and  clinical  course  of  intramural  sarcoma  in  the  be- 
ginning may  resemble  those  of  myoma  so  closely  as  to  make  the  clinical 
diagnosis  wholly  unreliable.  In  the  later  stages  the  clinical  course  and 
physical  signs  are  almost  identical  with  those  of  cancer. 

Sarcomatous  degeneration  of  myoma  (spindle-cell  sarcoma)  may  be 
suspected : 

1.  ^Vhen  hemorrhages  formerly  attributed  to  the  myoma   sud- 

denly increase  or,   having  ceased  for  a  considerable  time, 
begin  again  with  greater  violence. 

2.  When  after  the  onset  of  the  menopause  the  tumor  rapidly 

increases  in  size  and  becomes  softer. 

3.  When  the  growth  returns  after  removal. 

4.  When  ascites  suddenly  occurs. 

5.  When  cachexia  suddenly  appears. 

When  sarcoma  takes  the  place  of  myoma,  the  growth  rapidly  in- 
creases. Hitherto  painless,  it  now  causes  intense  suffering.  Watery, 
sanious  discharges,  after  the  onset  of  ulceration  and  gangrene,  have 
an  offensive  odor.  The  general  depression  is  out  of  proportion  to  the 
anaemia  and  inanition.  Pressure-symptoms,  cachexia,  and  emaciation 
are  pronounced,  and  of  rapid  development.  If  the  sarcoma  becomes 
polypoid,  the  pain  from  uterine  contractions  is  spasmodic,  and  hemor- 
rhages are  frequent  and  prolonged.  From  the  above  it  will  be  observed 
that  the  clinical  symptoms  and  course  are  substantially  the  same  as 
those  of  carcinoma,  but  uith  the  following  characteristics,  especially  in 
the  round-cell  varieties: 

The  vessels  having  no  adequate  walls,  hemorrhages  occur  more 
irregularly,  more  suddenly,  and  more  profusely  than  in  carcinoma. 
Ascites  occurs  earlier  than  in  carcinoma. 
Rectum  and  bladder  disturbance  not  pronounced;  these  viscera 

not  usually  involved,  as  they  are  in  carcinoma. 
Cachexia  earlier  than  in  carcinoma. 

Growth  and  necrotic  changes  more  rapid  than  in  carcinoma. 
Symptoms  referable  to  metastasis  more  common  because  metas- 
tatic extension  occurs  much  more  frequently  and  extensively 
than  in  carcinoma. 
Positive  diagnosis  is  only  possible  by  the  microscope. 

Treatment  of  Sarcoma  of  the  Uterus 

The  treatment  m.ay  be  either  radical  or  palliative,  and  is  the  same 
as  for  carcinoma,  viz.,  early  hysterectomy,  if  possible.  Unless  all  the 
growth  can  be  removed,  operation  hastens  death,  for  it  opens  the  venous 
channels,  and  thereby  favors  metastasis.  Palliative  hysterectomy — 
a  questionable  remedy  in  carcinoma — is  therefore  useless  in  sarcoma. 
The  operation  is  performed  the  same  as  for  cancer.  See  Hysterectomy 
for  Cancer.  The  spindle-cell  variety  being  less  malignant  than  the 
large  or  small  round  cell  would  clearly  offer  the  best  prospects  for  per- 
manent cure  as  a  result  of  hysterectomy,  since  the  glands  are  not  especi- 
ally apt  to  be  involved  in  sarcoma,  the  removal  of  them  is  not  required. 


CHAPTER   XXVII 
TUMORS  OF  THE   UTERUS 

DECIDUOMA   MALIGNUM— CHORIO-EPITHELIOMA 

Etiology  of  Deciduoma  Malignum 

Decidioma  malignum  is  confined  to  the  physiological  period  of 
maturity,  occurs  usually  between  the  ages  of  twenty  and  thirty-five, 
and  usually,  perhaps  always,  is  preceded  by  gestation  or  hydatidiform 
mole. 

Pathology  of  Deciduoma  Malignum 

Deciduoma  malignum,  first  described  in  1889,^  differs  radically  from 
all  other  neoplasms;  the  essential  element  is  a  giant  cell  embedded  in  a 
sarcoma-like  tissue. 

The  growth  is  of  foetal  origin,^  "the  tissue  entering  into  the  forma- 
tion of  it  being:  1.  Syncytium — i.  e.,  the  epithelial  layer  of  the  chorion. 
2.  The  so-called  cellular  layer — layer  of  Langhans — i.  e.,  the  ectoder- 
mal epithelial  layer  of  the  chorion."  The  disease  has  been  designated 
variously,  according  to  the  origin  of  the  growth. 

If  from  the  decidua  as : 

Deciduoma  adenomatosum. 
Deciduoma  carcinomatosum. 
Deciduoma  sarcomatosum. 

If  from  the  chorion  as : 
Chorioma  syncytiale. 
Chorioma  sarcomatosum. 

Deciduoma  malignum  is  circumscribed,  reddish  brown,  and  friable; 
it  presents  secondary  nodules,  and  commonly  extends  by  early  metas- 
tasis to  the  vagina,  ovaries,  broad  ligaments,  spleen,  kidney,  lungs, 
and  brain. 

The  growth  is  rich  in  blood  supply,^  and  the  blood  is  confined  within 
irregular  spaces;  the  vessels  have  no  adequate  walls;  hence  the  fre- 
quent hemorrhages.  Necrotic  changes  take  place  early.  Under  the 
necrosed  tissue  is  solid  tumor,  and  under  this  is  normal  uterine  tissue. 
In  the  development  of  the  growth  the  normal  constituents  of  the 
uterine  wall  are  replaced  rapidly  by  invasion  of  giant  cells  and  small 
round  cells. 

>  Sanger.     A  System  of  Gynecology,  by  Playfair. 
2  Marchand.     From  Playfair's  System  of  Gynecology. 

'  H.  M.  Jones.     "A  Clinical  and  Pathological  Study  of  Deciduoma  Malignum,"  '"Johns  Hopkins 
Hospital  Reports,  vol.  vi. 

26  ( 425  ) 


426  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Symptoms  and  Diagnosis  of  Deciduoma  Malignum 

Profuse  hemorrhage  occurring  during  the  puerperium  is  the  most 
characteristic  symptom;  it  is  intermittent  and  commonly  so  profuse 
as  to  cause  profound  anaemia.  Curettage  gives  but  transient  rehef. 
The  discharge  is  profuse,  watery,  and  often  foul-smelhng.  Hydatid- 
hke  moles  may  be  discharged  with  added  hemorrhage.  The  uterus 
rapidly  enlarges.  Metastasis  takes  place  by  the  venous  route,  most 
commonly  to  the  lungs,  and  gives  rise  to  symptoms  referable  to  the 
newly  infected  part.  Anaemia,  emaciation,  and  cachexia  follow  in 
rapid  succession.  Even  though  the  uterus  be  removed  early,  death  is 
usual  in  a  few  months. 

Physical  examination  shows  an  enlarged  uterus.  Smooth,  secondary 
nodules  may  be  felt  on  the  tubes.  The  uterine  cavity  may  be  open 
sufficiently  to  admit  the  finger.  Digital  exploration  then  will  detect 
masses  of  soft  tissue  and  coagula  of  blood  usually  localized  in  the 
uterine  wall.  The  above  history  and  symptoms  are  highly  diagnostic. 
Microscopical  examination  of  the  scrapings  will  establish  the  diagnosis. 

Prognosis  of  Deciduoma  Malignum 

Seventy-eight  per  cent,  of  all  cases  terminate  fatally  w^ithin  six 
months.     Deciduoma  malignum  is  one  of  the  most  malignant  of  all  tumors. 

Treatment  of  Deciduoma  Malignum 

Prophylaxis  requires  thorough  removal  of  all  retained  products  of 
conception  and  prompt  attention  to  post-abortion  and  puerperal 
hemorrhages.  The  surgical  treatment  is  the  same  as  that  already 
laid  down  for  carcinoma,  viz.,  early  hysterectomy.  Numerous  radical 
cures  have  been  reported.  Some  of  which  doubtless  were  in  cases  of 
wrong  diagnosis. 


PLATE    XX 


Solid  Carcinoma  of  the  Ovary,  with  Extension  of  the  Disease 

to  the  Intestinal  and  Parietal  Peritoneum 

and  to  the  Omentum. 


CHAPTER    XXVIII 
SOLID  TUMORS  OF  TIIK   ()^A1(^' 

Fibroma.     Myoma.     Sarcoma.     Carcinoma.     Benign  Papilloma. 

Sol, 11)  tumors  of  the  ovary,  like  some  ovarian  cysts  (intraligameii- 
tous),  may  (le\(>l()j)  between  the  folds  of  the  broad  ligament.  iNIore 
eommonly,  h()\ve\er,  solid  ovarian  tumors  lie  outside  of  the  broad 
Hgameiit.  A  pedicle  connects  the  tumor  with  the  uterus,  and,  as  in 
ovarian  cyst,  is  made  up  of  the  broad  ligament,  oviduct,  ovarian  liga- 
ment, and  o\arian  vessels.  xAbout  5  per  cent,  of  all  ovarian  tumors 
are  solid.  Solid  tumors,  even  though  not  malignant,  are  associated 
more  commonly  with  ascites  than  are  cystic  tumors. 

Fibromata  are  histologically  identical  with  similar  tumors  in  other 
organs.  Peterson^  has  collected  from  the  literature  84  cases;  he  finds 
that  fibromata  are  not  so  rare  as  formerly  supposed,  and  that,  con- 
trary to  the  usual  observation,  they  grow  sometimes  to  large  size; 
his  paper  is  one  of  the  most  complete  studies  of  the  subject  yet 
published. 

Myomata  are  of  rare  occurrence.  They  are  composed  of  the  usual 
unstriped  muscle-fiber  and  fibrous  tissue — fibromyoma.  The  muscle- 
fiber  is  traceable  from  the  ovary  to  the  ovarian  ligament.  Distinction 
between  the  myoma  and  the  spindle-cell  sarcoma,  even  with  the  micro- 
scope, is  not  always  easy.    These  tumors  sometimes  grow  to  large  size. 

Sarcomata  are  not  of  frequent  occurrence.  They  sometimes  occur, 
especially  in  childhood,  in  connection  with  dermoid  cysts,  or  follow 
the  remo^'al  of  dermoids.  The  spindle-cell  is  more  frequent  than  the 
round-cell  variety.  As  in  sarcoma  elsewhere,  rapid  growth,  speedy 
degeneration,  and  metastatic  invasion  of  other  organs  characterize  the 
disease.  Both  ovaries  are  apt  to  be  involved  primarily  at  the  same 
time. 

Carcinoma. — Little  is  known  of  primary  carcinoma  of  the  o\ary. 
It  arises  in  both  ovaries  at  the  same  time.  Secondary  carcinoma  may 
occur  by  extension  from  neighboring  organs  or  by  metastasis. 

Benign  Fapillomata  (solid  warty  growth)  arise  from  the  outer  sur- 
face of  the  ovary;  they  may  spread  to  the  peritoneum  and  broad  liga- 
ments, and  may  undergo  malignant  changes.  See  Papillomatous 
Cysts  in  the  following  chapter. 

Diagnosis  of  Solid  Ovarian  Tumors. — Solid  ovarian  tumors  may  be 
recognized  one  from  the  other,  from  cystic  tumors,  and  from  other 
pelvic    conditions   by   the    clinical    history,   conjoined    manipulation, 

'  American  Gynecology,  July,  1902. 

(427) 


428 


TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


exploratory  incision,  and  microscopical  examination.  The  clinical  history 
often  will  suffice  to  separate  the  malignant  from  the  benign  growths. 
Conjoined  examination  will  outline  a  tumor  in  the  ovarian  region, 
will  show  that  it  is  not  connected  with  the  uterus,  and  will  determine 
its  size,  form,  mobility,  and  consistence.  Exploratory  incision  will 
define  further  its  physical  characteristics  and  its  exact  relation  to 
adjacent  organs.     The  diagnosis  is  concluded  by  the  microscope. 


Figure  197 

^f^ 

^-^. 

ii 

.■  »^^k           ^^^^Kl 

\ 

w 

^  <» 

^9H^^^Ei>I"^''':^a^^^^H^E| 

s^^ip 

w" 

>!. 

W 

# 

^JH^               .JB^^pl^^^^l 

% 

.. 

^ 

^ 

IPP^                             '/  ^^'J 

Ki  ^^^^B 

tS   .  j^l  -« 

/ 

Solid  sarcoma  of  the  ovary,  weight  four  pounds.  Observe  the  smooth  cut  surface,  characteristic 
of  sarcoma,  as  compared  with  the  uneven  surface  of  a  uterine  myoma.  Author's  case;  ovariotomy; 
recovery. 


Treatment  of  Solid  Ovarian  Tumors. — The  treatment  of  all  benign  or 
malignant  tumors,  large  or  small,  is  early  removal.  The  operation  is 
the  same  as  for  cystic  ovarian  tumors.    See  Ovariotomy. 


CHAPTER  XXIX 
OVARIAN  AND   PAROVARIAN   CYSTS 

The  ovary  consists  of  two  parts: 

1.  The  outer  cortical  or  egg-bearing  part,  called  the  Cortex  and 
containing  the  Graafian  follicles. 

2.  The  inner  zone,  which  never  contains  follicles  or  ova;  this  part 
is  in  relation  with  the  hilum  of  the  ovary,  is  composed  of  fibrous  tissue 
and  traversed  by  numerous  blood-vessels  and  is  called  the  vascular 
or  medullary  portion. 

In  relation  with  the  ovary  and  situated  in  the  broad  ligament  is  a 
remnant  of  the  Wolffian  body,  which  has  no  physiological  significance, 
called  the  Parovarium. 

Cystic  tumors  may  arise: 

1.  From  any  portion  of  the  ovary— Ovarian  Cysts. 

2.  From  the  parovarium — Parovarian  Cysts. 

OVARIAN   CYSTS 

Pathology  of  Ovarian  Cysts 

A  cystic  ovary  may  present  a  single  cavity  containing  fluid  enclosed 
in  a  sac  wall  and  then  is  termed  a  monocyst,  that  is,  a  unilocular  cyst; 
commonly  there  are  many  cavities  or  compartments  in  which  case  it 
is  known  as  a  polycyst  or  multilocular  cyst. 

Some  ovarian  tumors  wrongly  classed  as  monocysts  may  have  appar- 
ently a  single  cavity,  but  close  examination  may  show  numerous  small 
loculi  in  their  walls.  Sometimes,  imperfect  septa  or  bands  running 
from  one  part  of  the  cyst-wall  to  another  are  remnants  of  these  walls 
and  show  that  the  cyst  originally  was  multilocular. 

Ovarian  cysts  according  to  their  origin  or  character  are  divided  as 
follows: 

1 .  Follicular  cysts  (multilocular  from  degenerated  Graafian  f olicles) . 

2.  Corpus  luteum  cysts  (usually  unilocular). 

3.  Cyst-adenomata,  usually  multilocular,  subdivided  as  follows: 

a.  Simple. 
h.  Papillary. 

4.  Dermoid  cysts. 

1.  Follicular  Ovarian  Cysts. — Follicular  cysts  due  to  inflammatory 
changes  and  shown  in  Figure  197  as  microcystic  degeneration  of  the 
ovary  have  been  described  in  the  chapter  on  Ovaritis.     Putting  aside 

(429) 


430 


TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


the  possible  relations  of  these  retention  cysts  to  ovarian  tumors,  we  may 
describe  a  genuine  follicular  cystic  neoplasm,  which  may  cause  consider- 
able enlargement  of  the  ovary.  A  number  of  follicles  take  on  cystic 
degeneration,  giving  rise  to  many  small  adjacent  cysts  which  may  by 
the  destruction  of  the  partitions  between  them  run  together  and  form 
one  or  more  larger  cysts. 


Figure  198 


Gartner's   Duct 


Y   A  R  O  V^.4  jR  /  ir 


K 


H 


Cyst-producing  region  of  the  ovary  and  its  surroundings: 

A.   Uterus,  Fallopian  tube,  parovarium,  and  ovary.  ,    „r  ,^         i_     , 

B  Gartner's  duct  (remnant  of  Woffian  duct),  parovarium  (remnant  of  vv  olttian  body  or  meso- 
nepliros)  and  ovary  shown  in  section:  P,  vascular  or  medullary  zone;  O,  oophoron — this  is  the  egg- 
bearing  portion.-  sometimes  called  parenchymatous  zone,  sometimes  the  cortical  portion ;  -S,  free  external 
surface  of  ovary;  K,  Koblet's  tubes.     Semi-diagrammatic. 

The  wall  of  a  follicular  cyst  is  composed  of  three  layers:  an  outer 
layer  of  endothelial  cells  or  in  small  growths  of  cuboidal  epithelium; 
a  middle  layer  of  white  fibrous  tissue  containing  blood-vessels  and 
lymphatics;  an  inner  layer  of  membrana  granulosa  like  that  of  the 
Graafian  follicle.  This  membrana  granulosa  is  maintained  until  the 
cyst  reaches  the  approximate  size  of  an  egg.  In  tumors  the  size  of 
an  orange  the  lining  layer  changes  finally  to  a  flat  epithelium.  In 
large   cysts   containing   much   more   fluid   the   epithelium   disappears 


OVAh'lAX   AM)   I'AROVAUIAX   CYSTS 


4;u 


by  atrophy  and  ^iNcs  way  to  fihrous  tissiu'.  The  atrcjjjhic-  process  is 
due  to  pressure  of  the  (hiid  conteiits.  Tlie  Huid  is  apt  to  be  identical 
with  niiicus.  a  tact  (h)ul)th'ss  owiny'  to  the  hnin^-  ot"  epithcHuni. 


Figure  199 


Microcystic  degeneration  of  the  ovary;  the  ovary  to  the  right  shows  numerous  small  rxsts  scattered 
over  the  surface;  these  are  Graafian  follicles  which  have  undergone  cystic  degeneration,  and  which 
it  is  said  may  take  on  excessive  growth  and  develop  into  large  tumors,  or'  ma\-  remain  as  here  repre- 
sented; on  the  other  side  is  shown  a  similar  condition  of  the  ovary  in  section. 


2.  Corpus  Luteum  Cysts. — The  wall  of  a  corpus  luteum  cyst  some- 
times may  be  recognized  by  the  wavy  aspect  and  yellow  color  of  its 
inner  surface.  The  external  layer  is  composed  of  connective-tissue 
stroma  containing  blood-  and  lymph-vessels  around  which  at  many 
points  are  groups  of  round  cells;  these  vessels  pass  perpendicularly 
to  the  middle  layer  which  contains  as  a  characteristic  of  this  form  of 
cyst,  lutein  cells.  The  inner  layer  shows  cellular  elements  which  are 
undergoing  retrogressive  changes  and  is  not  distinctly  separable  from 
the  cyst  contents.  These  cysts  are  usually  small,  rarely  growing  to  the 
size  of  an  orange.  They  commonly  have  a  thick  wall  and  contain  a 
yellow,  watery  fluid  which  is  said  to  get  its  color  from  the  pigment 
of  the  lutein  cells.  Corpus  luteum  cysts  usually  if  not  always  are 
monocystic. 

3.  Cyst-adenomata. — Often  called  proliferating  cysts,  the  most  com- 
mon form  of  ovarian  tumors,  unlike  follicular  cysts,  frequently  grow 
to  enormous  size.  They  are  characterized  by  rapid  growth  and  by 
having  the  capacity  to  secrete  great  quantities  of  fluid,  and  are  divided 
into : 

a.  Simple  cyst-adenomata,  which  have  smooth  inner  walls. 

b.  Papillary  cyst-adenomata,  the  inner  walls  of  which  produce  warty 
growths. 

a.  Simple  Cyst-adenomata  are  usually  multilocular  in  origin.  As  in 
follicular  cysts  the  compartments  between  the  cavities  of  a  multilocular 
cyst  may  disappear  and  form  a  single  cystic  cavity,  so  that  a  multi- 
locular cyst  may  become  unilocular.  The  multilocular  cyst  commonly 
has  one  large  primary  cavity,  and  a  number  of  smaller  adjacent  cavities, 
which  have  formed  in  the  walls  of  the  original  cyst.     Cystic  develop- 


432 


TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


ment  may  continue  until  the  tumor  becomes  enormous,  a  burden  to 
the  patient,  and  a  destroyer  of  Hfe.  The  walls  are  traversed  by  large 
blood-vessels  and  are  lined  with  glandular  cylindrical  epithelium 
sometimes  ciliated,  which  continuously  produces  large  quantities  of 
fluid  and  may  preserve  its  integrity  in  spite  of  the  pressure  exerted  upon 
it  by  the  cyst  contents.  Adenomatous  cysts  of  the  ovary  have  some 
tendency  to  become  malignant;  hence  the  importance  of  early  removal. 
The  walls  are  more  or  less  thick  according  to  the  degree  of  distension, 
and  are  composed  largely  of  connective  tissue.  Cyst-adenomata  usually 
contain  a  thin  clear  sticky  fluid  which  from  admixture  of  blood  may 
become  red  or  chocolate-colored,  and  in  which  chemical  tests  show  the 
presence  of  pseudomucin.  Figures  200  and  201  show  two  views  of  a 
cyst-adenoma,  one  of  which  is  in  section. 


Simple  cyst-adenoma.     Multilocular  ovarian  cyst,  sometimes  called  ovarian  adenoma. 

b.  Papillary  Cyst-adenomata. — Papillomatous  cysts  characterized  by 
warty  growth,  more  commonly  develop  in  the  hilum  or  in  the  medullary 
portion  of  the  ovary.  They  usually  contain  a  clear,  thin,  yellowish 
fluid,  which  may  be  reddish  from  admixture  of  blood.  In  chemical 
properties  and  microscopical  appearance  this  fluid  resembles  that  of 
ordinary  cysts.  The  fluid  may  be  mixed  with  a  tenacious  colloid 
substance.  These  cysts  seldom  attain  the  size  of  ordinary  ovarian 
cysts;  are  usually  unilocular  and  frequently  develop  between  the  layers 
of  the  mesosalpinx.  With  increased  growth  they  may  separate  the 
layers  of  the  broad  ligament  and  force  their  way  between  them  to  the 
lateral  walls  of  the  uterus,  and  will  then  feel  on  digital  touch  like  an 


OVARIAN  AND  PAROVARIAN  CYSTS 


433 


oiitj^Towtli   from  the   uterus.     They   present,  especially  on  tlie  inside, 

in  \ariat»le  (pianlity,  warty  or  |)apilloniatous  f;TC)\\tlis,  wliicji  liistolo^ie- 


Section  of  simple  cyst-adenoma.     Multilocular  ovarian  cyst,  sometimes  called  ovarian  adenoma,  m 
section;  the  larger  cavity  is  primary;  the  smaller  cavities,  secondary. 


Figure  202 


Papillomatous  ovarian  disease.  On  the  right  side  is  a  cyst  from  the  vascular  zone  of  the  ovary; 
in  the  wall  of  this  cyst  liave  developed  three  secondary  cysts,  which  are  shown  in  section  and  whicli 
contain  warty  growths;  observe  also  the  warty  growths  both  on  the  outside  and  inside  of  the  cyst; 
to  the  left  is  a  superficial  papilloma  of  the  ovary,  which  Ues  between  the  ovary  and  the  uterus.  Papillo- 
matous disease  on  the  inside  of  this  ovary  is  also  shown  in  section. 


434  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

ally  are  the  same  as  warty  growths  in  other  parts  of  the  body,  and 
which  may  penetrate  the  cyst-wall  to  the  peritoneum  and  to  adjacent 
organs. 

The  cyst-w^all  is  composed  of  the  usual  fibrous  tissue,  which  has  an 
inner  lining  of  cylindrical  epithelium.  The  source  of  this  epithelium 
is  not  definitely  known.  It  is  thought  by  some  to  be  from  remnants  of 
epithelium  from  the  Wolffian  body.  At  any  rate  it  has  the  power  of 
producing  a  most  abundant  warty  growth  which  proliferates  rapidly, 
bleeds  freely  on  manipulation,  is  usually  soft  and  friable,  varies  in 
quantity  from  that  of  the  smallest  wart  to  that  of  an  orange,  may  be 
either  sessile  or  pedunculated,  and  according  to  the  variable  blood- 
supply,  pale  or  pink.  These  papillomatous  elements  may  so  increase 
in  quantity  as  to  force  their  way  by  rupture  or  perforation  through  the 
cyst-wall,  spread  over  the  outside,  and  affect  the  adjacent  peritoneum. 
Extension  of  the  disease  is  by  continuity  of  tissue  or  surface,  not  by 
way  of  the  vessels.  Warty  ovarian  cysts  may  be  associated  with  der- 
moids, and  occasionally  wdth  sarcoma  of  the  ovary.  Tapping  of  the 
cyst  has  resulted  in  escape  of  the  fluid  into  the  abdominal  cavity,  and 
infection  of  the  peritoneum. 

There  are  other  papillomatous  tumors  found  in  the  ovary  and  broad 
ligaments  which  have  not  developed  from  the  medullary  portion  or 
hilum  of  the  ovary;  these  cysts,  according  to  Sutton,  may  be  in  any 
part  of  the  ovary  are  usually  multiple,  present  warts  of  almost  carti- 
laginous hardness,  and  may  be  associated  with  uterine  myomata. 

Clinically  speaking,  papilloma  of  the  uterine  appendages,  whether 
solid  or  cj'stic,  is  on  the  border  line  between  benign  and  malignant 
growths.  Frequent  tappings  of  ascitic  accumulations  extending  over 
a  period  of  several  years  have  been  recorded  in  connection  with  inoper- 
able cases.  The  stronger  the  malignant  tendency,  the  more  pronounced 
the  ascites.  Papillomata  may  give  rise  to  great  embarrassment  in  the 
removal  of  the  tumor,  for  if  any  of  the  warty  growths  are  left  behind 
they  are  apt  to  spread  rapidly  and  render  the  operation  useless.  On 
the  contrary,  if  they  are  all  removed  the  ascites  may  be  expected  to 
disappear  and  the  patient  to  become  permanently  well.  Even  in  the 
cases  of  extensive  warty  development,  if  there  is  hope  of  complete  re- 
moval, the  radical  operation,  even  to  the  extent  cf  combined  ovariotomy 
and  hysterectomy,  shonld  be  attempted. 

4.  Dermoid  Cysts. — Dermoid  ovarian  cysts  are  distinguished  from 
follicular  cysts  and  cyst-adenomata  by  the  inner  lining  of  the  cyst-wall, 
which  is  made  up  of  squamous  epithelium  and  papillae  like  external 
skin.  The  cyst-wall  contains  an  outer  layer  of  connective  tissue. 
Dermoid  cysts  are  found  not  only  in  the  ovary  but  also  in  various  other 
parts  of  the  body.  The  quantity  of  dermoid  elements  is  variable. 
Cutaneous  structures  may  line  an  entire  cyst  or  may  be  confined  to 
small  isolated  areas.  Sometimes  dermoid  elements  are  contained  in  a 
single  small  compartment  of  a  large  multilocular  cyst-adenoma  so  that 
the  dermoid  character  of  the  growth  may  be  overlooked.  Two  classes 
are  recognized: 


OVAh'IAN  AND   PAROVARIAN  CYSTS 


435 


1.  Simple  dermoid  cysts. 

'2.  ("()in])li('ate(l  dermoid  cysts— teratomata. 
1.  Simple  Dermoid  Cysts.-  'I'he  siini)ic  dermoid  cyst  has  a  very  dis- 
tinct inner  lining'  of  inte,unm(Mit,  consistini;'  of  fiat  ei^ithelium,  i)ai)illa', 
and  sebaceous  glands.  Tlie  cyst-wall  and  the  cyst-cavity  may  contain 
much  hair,  skin,  nails,  teeth,  sebaceous  matter,  and  a  yellowish  fat.  As 
a  rule,  these  tumors  do  not  <i,Tow  to  the  great  size  of  cyst-adenomata. 
The  hair  is  sometimes  present  in  great  abundance,  and  may  be  matted 
together  in  the  form  of  a  round  ball  the  size  of  an  orange.  According 
to  Sutton,  the  color  is  variable,  does  not  necessarily  correspond  with 
that  of  the  head  of  the  patient,  and  in  aged  people  may  be  gray  or 
may  have  been  shed,  leaving  the  wall  of  the  c>'st  bald.  Extensive 
involvement  of  both  ovaries  in  dermoid  cystic  disease,  even  though 
little  normal  ovarian  tissue  remains,  does  not  positively  render  the 
woman  sterile.  In  one  case,  reported  by  Cullingworth,  the  patient,  at 
the  age  of  thirty-nine,  had  had  twelve  children,  the  last  being  three 
months  old  at  the  time  of  the  removal  of  the  two  dermoid  ovaries. 

FiGUHE    203 


Dermoid  ovarian  cyst  in  section,  showing  inside  of  cyst-cavity,  which  contains  a  lower  jaw  and  a 
fragment  of  another  jaw,  with  teeth,  small  fragments  of  bone,  and  considerable  hair;  the  upper  mass 
of  hair  is  in  the  shape  of  a  ball,  and  is  held  together  by  the  fatty  contents  of  the  cyst,  which,  at  the 
temperature  of  the  body,  is  hquid,  but  becomes  solid  upon  exposure  to  the  ordinary  temperature  of 
the  air,  that  is,  about  70°  F.     Observe  the  imperfect  lower  jaw  with  numerous  well-formed  teeth. 


Dermoid  tumors  occur  at  all  ages,  from  infancy  to  extreme  senility. 
They  occasionally  are  found  in  children,  and  are  not  uncommon  in 
young  women.     Unlike  other  forms  of  ovarian  cysts  which  destroy  life 


436  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

in  three  or  four  years,  simple  dermoids  may  exist  for  a  lifetime  and 
give  little  or  no  inconvenience.  They  have  been  found  post-mortem 
in  aged  women,  who  may  have  had  them  from  the  period  of  sexual 
maturity  and  never  had  been  aware  of  their  presence.  Like  other 
cysts,  however,  they  may  at  any  time  undergo  suppurative,  malignant, 
and  other  degenerative  changes  and  therefore  become  dangerous. 

The  fluid  content  of  a  pronounced  dermoid  cyst  is  an  oily  fat,  which 
is  fluid  at  the  temperature  of  the  body,  but  at  a  lower  temperature,  semi- 
solid. The  fatty  contents  are  very  irritating  to  the  peritoneum,  and 
when  a  cyst  breaks  into  the  peritoneal  cavity  the  epithelial  elements 
of  it  may  engraft  themselves  upon  the  peritoneum  and  give  rise  to 
secondary  growths. 

2.  Complicated  Dermoid  Cysts  (Teratomata). — In  addition  to  the 
dermoid  elements  mentioned  above,  dermoid  cysts  may  contain  other 
structures  of  the  body,  such  as  bones,  teeth,  fragments  of  the  brain, 
muscle,  and  cartilage,  even  an  entire  finger  has  been  observed.  Such 
tumors  are  apt  to  be  of  the  solid  rather  than  of  the  cystic  variety, 
and  are  called  teratomata.  The  presence  of  bone  and  teeth  does  not 
characterize  them  as  especially  inclined  to  malignant  degeneration, 
but  when  numerous  other  embryonal  structures  of  the  different  layers 
of  the  blastoderm,  brain,  muscle,  nerve,  cartilage,  fat,  and  bone  are 
thrown  together  throughout  the  tumor  in  a  confused  mass  the  growth 
should  be  regarded  as  having  a  decided  malignant  tendency.  Tera- 
tomata have  been  classified  as  simple  growths,  which  contain  dermoid 
elements,  teeth,  and  bone,  and  as  complicated  growths  which  contain 
the  other  structures  above  mentioned. 


PAROVARIAN   CYSTS 

Pathology  of  Parovarian  Cysts 

The  parovarium  from  which  parovarian  cysts  spring  is  the  remnant 
of  the  Wolffian  body  (primitive  kidney)  and  has  no  known  physiological 
significance.  If  the  broad  ligament  is  stretched  and  held  up  to  the 
light,  a  series  of  small  tubules  will  be  seen  radiating  from  the  ovary 
and  joining  at  right  angles  a  longitudinal  tube.  The  tubules  are  the 
parovarium.  See  Figure  199.  They  are  of  two  kinds:  1.  The  ver- 
tical tubules.  2.  The  outer  tubules,  free  at  one  end — Kobelt's  tubes. 
All  these  tubules  join  a  longitudinal  tube — Gaertner's  duct.  This  duct 
is  the  homologue  of  the  vas  deferens  in  the  male;  occasionally  it  may 
be  traced  downward  to  the  vagina.  The  parovarium  lies  between  the 
folds  of  the  mesosalpinx. 

The  little  tubules  of  Kobelt  very  often  are  distended  by  their  fluid 
contents  into  cysts,  usually  no  larger  than  a  pea.  These  cysts,  which 
have  little  or  no  significance,  frequently  are  confounded  with  the  hydatid 
of  ]\Iorgagni  which  may  grow  to  such  considerable  size  as  to  be  a 
mechanical  irritant  and  require  removal.     Figure  204.     A  distended 


OVARIAN  AND  PAROVARIAN  CYSTS 


437 


vertical  tubule  may  become  separated  and  form  a  pedunculated  cyst. 
This  may  rupture,  discharge  its  contents  into  the  abdominal  cavity, 
and  become  obliterated.  The  remnant  of  the  cyst-wall  then  presents 
a  fringe-like  appearance. 


FiGum-;  204 


Small  parovarian  cyst.  This  cyst  has  sprung  from  the  parovarium,  and  is  therefore  entirely  distinct 
from  the  ovary;  to  the  right  is  the  hydatid  of  Morgagni  suspended  from  a  long,  slender  pedicle,  which 
is  attached  to  one  of  the  fimbriated  extremities  of  the  Fallopian  tube.  The  hydatid  of  Morgagni  has 
been  known  to  grow  to  the  size  of  a  small  orange,  and  it  then  has  the  same  general  appearance  as  the 
parovarian  cyst,  but  is  distinguished  from  it  by  the  fact  that  it  springs  from  the  extremity  of  the 
Fallopian  tube.  The  Fallopian  tube  shows  numerous  points  of  expansion  and  constriction,  one  of 
them  being  at  the  isthmus;  this  is  known  as  salpingitis  isthmica  nodosa,  common  in  gonorrhceal  salpin- 
gitis. Myoma  and  adenomyoma  of  the  tube  present  a  gross  appearance  similar  to  that  of  salpingitis 
isthmica  nodosa.    This  condition  of  the  tube  is  rarely  found  in  connection  with  cysts  of  the  parovarium. 


The  usual  parovarian  cyst  is  unilocular,  that  is,  it  springs  from  a 
single  vertical  tubule,  and  most  commonly  develops  without  a  pedicle, 
and  remains  between  the  layers  of  the  mesosalpinx.  As  it  grows  larger 
it  may  force  its  way  between  the  layers  of  the  broad  ligament  and 
lie  in  close  relation  with  the  uterus;  hence  the  name  broad  ligament 
cyst  is  sometimes  applied  to  it.  The  Fallopian  tube,  with  its  fimbriated 
extremity  attached  to  the  ovary  and  its  uterine  end  to  the  uterus,  has 
been  stretched  over  the  enlarging  cyst-wall,  and  is  enormously  elongated. 

The  walls  of  small  cysts  are  usually  quite  thin  and  transparent; 
when  larger  they  become  thick,  opaque,  pearly-like,  and  of  conjunctival 
blue  color.  The  lining  of  the  small  cysts  preserves  the  columnar  epithe- 
lium of  the  tubule;  in  larger  cysts  the  epithelium  becomes  flattened; 
in  the  largest  cysts  the  atrophic  influence  of  pressure  may  be  so  great 
as  entirely  to  destroy  the  epithelium. 

Unlike  the  ovarian  cyst,  which  is  a  diseased  ovary,  the  parovarian 
cyst  usually  has  a  flattened  ovary  attached  to  the  side  of  it.  The  fluid 
is  almost  always  clear  and  colorless,  like  spring  water;  the  nitric-acid 
and  heat  tests  may  show  a  trace  of  albumin.  The  specific  gravity 
is  usually  much  less  than  1010.  The  reaction  is  faintly  acid.  See 
Tabular  Diagnosis  between  Parovarian  and  Ovarian  Cysts  in  the 
following  chapter.  Adhesions  rarely  form  about  these  cysts.  The 
peritoneal  covering  may  be  stripped  off  easily,  and  the  cyst,  therefore, 
easilv  enucleated. 


438  TUMORS,    TUBAL   PREGNANCY,    MALFORMATIONS 

The  parovarium  does  not  often  take  on  demonstrable  cystic  disease 
before  the  age  of  puberty,  the  more  common  age  for  development 
being  from  eighteen  to  thirty-five.  These  cysts  do  not  tend  to  rapid 
degeneration,  and  therefore  may  be  carried  for  years  with  little  or  no 
danger.  Rupture  of  the  cyst  sometimes  is  followed  h\  obliteration 
and  cure. 

Figure  205 


Parovarian  cj'st.     Observe  the  ovary  separate  from  the  cyst  and  the  long,  stretcherl-out  Fallopian 


tube  whioh  siirrounds  the  cyst  wall 

Cyst  of  the  Broad  Ligament  is  a  name  reserved  by  many  to  desig- 
nate parovarian  cysts.  Various  other  cysts,  however,  also  develop  in 
the  broad  ligament.  The  name,  therefore,  has  no  definite  significance 
beyond  the  fact  that  it  designates  a  cyst  situated  between  the  layers 
of  the  ligament.  Such  a  cyst  may  originate  in  the  ovary  and  gradually 
force  its  way  between  the  folds  of  the  broad  ligament,  or  may  develop 
from   a   congenitally   intraligamentous   ovary.      It   not   uncommonly 


OVARIAX  AXD  PAROVARIAN  CYSTS 


439 


originates  near  the  hilum  of  the  o\ary,  and  the  fjreat  majority  of  broad 
Hganient  cysts  are  eitlier  of  this  sort  or  parovarian.  When  they  are 
of  ovarian  origin  they  are  called  intralifjamentous  ovarian  cysts. 

Secondary  Changes  in  Ovarian  and  Parovarian  Cysts. — The  principal 
secondary  chanues  in  oxarian  and  paro\arian  cysts  are: 

1.  Changes  in  the  fluid  contents. 

2.  Infection. 

3.  Twisting  of  the  i)ediclc. 

4.  Rupture  of  the  cyst. 

In  addition  to  the  above  secondary  changes  may  be  mentioned  the 
following  degenerative  changes  in  the  cyst-wall:  Fatty  degeneration, 
calcareous  degeneration,  myxomatous  degeneration,  and  malignant 
degeneration    (sarcoma   and   carcinoma). 

FlGTRE    20(3 


Tubo-ovarian  cyst  or  abscess.     Sometimes  the  sac  of  a  tubo-ovarian  cyst  suppurates;  it  is  then  known 

as  a  tubo-ovarian  abscess. 


1.  Changes  in  the  Fluid  Contents  of  a  cyst  may  occur  as  follows:  The 
fluid  naturally  contained  in  an  ovarian  cyst  is  usually  transparent, 
clear,  of  a  light-straw  color,  and  of  a  specific  gravity  varying  from 
1010  to  1050.  In  the  progress  of  the  disease  secondary  changes  occur 
which  make  the  widest  variation  in  the  physical  properties  of  the 
fluid.  This  variation  is  caused  by  the  admixture  of  blood,  pus,  fat, 
epithelial  cells,  cholesterin,  and  by  chemical  changes.  The  fluid,  there- 
fore, may  be  thick,  thin,  dark,  light,  clear,  muddy,  or  chocolate-colored. 


440  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Different  fluids  may  be  present  in  the  different  compartments  of  the 
same  cyst. 

2.  Infection. — The  Fallopian  tube  is  doubtless  the  greatest  carrier 
of  infection.  This  may  be  inferred  from  the  fact  that  when  an  infected 
cyst  becomes  adherent  to  adjacent  organs  the  strongest  adhesions  usually 
are  found  where  infection,  if  it  came  through  the  tube,  would  first 
reach  the  cyst — viz.,  about  the  abdominal  end  of  the  tube.  Inflamma- 
tion is  confined  to  the  neighborhood  of  the  tube,  but  may  extend  in- 
definitely over  the  tumor,  gluing  it  to  adjacent  peritoneal  surface, 
visceral  or  parietal,  and  may  penetrate  the  cyst-wall. 

The  intestine  and  bladder,  if  inflamed,  are  prolific  sources  of  infection. 
The  inflamed  gut  readily  adheres  to  the  cyst-wall,  and  becomes  softened 
by  the  inflammatory  process  or  thin  from  the  atrophic  results  of  pres- 
sure. Extensive  infection  of  a  cyst  may  be  traceable  in  some  cases  to 
an  inflamed  adherent  vermiform  appendix.  In  acute  suppuration 
conditions  rapidly  become  grave;  they  are:  sudden  enlargement  of 
the  tumor  with  severe  pain  and  tenderness,  rapid  and  weak  pulse, 
high  temperature  and  exhaustion.  Putrefactive  processes  maj^  lead 
to  the  penetration  through  the  cyst-wall  of  germ-bearing  gases  which 
will  give  rise  to  a  tympanitic  note  on  percussion  over  the  tumor.  In 
rare  cases  rupture  of  the  sac  and  discharge  of  its  purulent  contents 
through  the  intestine  or  some  other  viscus  may  avert  a  fatal  result 
which  otherwise  could  only  be  prevented  by  prompt  ovariotomj'. 

Tuho-ovarian  Cyst  and  Tuho-ovarian  Abscess,  as  set  forth  in  the 
chapter  on  Salpingitis,  may  form  as  follows:  The  adhesion  of  a  sacto- 
salpinx  to  an  ovary  may  be  followed  by  the  bursting  of  a  small  ovarian 
cyst  or  a  corpus  luteum  into  the  tube  and  the  establishment  of  a  per- 
manent communication  between  the  two.  During  the  growth  of  the 
tubal  sac,  which  is  now  part  of  a  tubo-ovarian  cyst,  the  ovarian  cyst 
is  subject  to  the  same  pressure  as  the  walls  of  the  tube;  hence  the 
ovarian  structure  becomes  flattened  so  as  to  form  a  thin  wall  for  the 
ovarian  portion  of  the  composite  cyst,  and  thus  the  characteristic 
structure  of  the  ovary  is  lost.  Tubo-ovarian  cyst  may  occur  in 
connection  with  hydrosalpinx  or  pyosalpinx.  If  the  sactosalpinx 
communicates  with  an  ovarian  abscess  the  condition  is  called 
tubo-ovarian   abscess. 

Adhesions  are  among  the  most  constant  results  of  inflammation. 
Formerly  they  were  the  bete  noir  of  the  surgeon.  Now,  with  improved 
technique,  tumors  that  formerly  would  have  been  abandoned  after  an 
exploratory  incision  are  removed  almost  always.  Adhesions  may  be 
abdominal  or  pelvic,  visceral  or  parietal.  Visceral  adhesions  are  those 
which  unite  the  tumor  to  the  uterus,  bladder,  liver,  and  other  abdomi- 
nal or  pelvic  viscera.  Adhesions  to  the  omentum  are  common  and 
often  extensive.  Intestinal  adhesions  sometimes  give  rise  to  danger- 
ous, even  fatal,  obstruction  of  the  bowel.  Pelvic  adhesions  are  more 
inaccessible,  and  therefore  more  dreaded  than  parietal.  Two  large 
ovarian  cysts,  one  from  the  right  and  the  other  from  the  left  ovary, 
may  come  in  contact  with  each  other  and  become  strongly  and  broadly 


OVARIAX   AM)   rWROVARIAX   CYSTS  441 

united.     The  difficulties  of  diagnosis  and  operative  renKnal  are  then 
much  increased. 

;i.  Twisting  of  the  Pedicle. — Most  ovarian  cysts  are  pedunculated, 
the  pedicle  being  made  up  of  structures  which  connect  the  cyst  with 
the  uterus,  /.  e.,  broad  ligament,  round  ligament,  Fallopian  tube, 
ovarian  artery,  and  ovarian  vein.  Acute  Torsion  is  due  to  a  sudden 
rotation  of  the  cyst  with  sufficient  twisting  of  the  pedicle  to  cut  off 
circulation  and  to  set  up  grave  symptoms.  Chronic  Torsion  is  due  to 
gradual  rotation  of  the  cyst  with  slow  twisting  of  the  pedicle,  which 
gives  the  tumor  an  opportunity  to  adjust  itself  to  the  changed  condi- 
tions. It  is  less  severe  and  the  course  more  prolonged  than  that  of 
acute  torsion,  since  the  impaired  circulation  may  be  restored  partially 
through  adhesions.  The  pedicle  in  rare  cases  is  twisted  off  completely. 
The  detached  tumor  then  must  receive  its  blood-supply,  if  at  all,  by 
way  of  vessels  which  reach  it  only  through  adhesions.  Among  the 
conditions  which  may  give  rise  to  this  accident  are:  alternate  distension 
and  evacuation  of  the  bladder  or  bowel;  a  fall  or  other  violence;  violent 
exertion,  tight-lacing;  growing  pregnant  uterus,  and  long  slender  pedicle, 
especially  if  associated  with  ascites. 

The  results  of  torsion  are:  cedema  from  obstruction  to  the  circula- 
tion in  the  sac-wall  due  to  compression  of  blood-vessels  as  they  pass 
through  the  twisted  pedicle  and  engorgement  of  the  sac  which  may 
cause  only  occasional  extravasations  of  blood  from  small  vessels,  or 
may  be  so  intense  as  to  cause  rupture  of  larger  vessels,  and  consequent 
profuse  hemorrhage  into  the  sac  and  great  distension  and  rupture  of 
the  cyst-wall,  and  discharge  of  the  cyst  contents  into  the  abdomen. 
Rotation  is  sufficiently  acute  to  cut  off  the  circulation,  will  result 
usually  in  gangrene  of  the  cyst,  hemorrhage  into  the  cyst,  peritonitis, 
sepsis,  and  suppuration.  There  w^ill  be  rapid  increase  in  the  size  of  the 
tumor  which  quickly  grows  more  and  more  tense  with  acute  pain 
followed  not  infrequently  by  sudden  disappearance  of  the  tumor  from 
rupture.  Unless  relief  comes  from  prompt  ovariotomy  death  is  almost 
certain.  In  the  less  acute  or  chronic  cases,  the  circulation  not  being 
entirely  cut  off,  there  will  be  oedema  in  the  sac-wall,  engorgement 
and  extravasations  of  bloofl  from  small  vessels  or  rupture  of  larger  ones 
with  consequent  hemorrhage  into  the  sac,  and  possibly  rupture,  or 
there  may  be  extensive  adhesions  which  will  render  a  delayed  operation 
difficult  and  extra-hazardous. 

4.  Rupture  of  the  Cyst. — The  cyst  may  rupture  into  the  abdominal 
cavity,  or  into  some  one  of  the  abdominal  viscera.  One  cavity  of  a 
multilocular  cyst  may  rupture  into  another.  Thin-walled  secondary 
compartments  very  commonly  rupture  into  the  abdominal  cavity, 
leaving  the  remaining  compartments  of  the  cyst  intact. 

Rupture  of  the  cyst  may  occur  as  the  result  of  the  following  conditions: 

Softening   or   thinning   of   the    cyst-wall    from    inflammation    or 
distension. 

Hemorrhage  into  the  cyst-wall  or  into  the  sac. 

Fatty  degeneration,  necrosis,  or  gangrene  of  tlie  cyst-wall. 

27 


442  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Suppuration  in  the  cyst. 

Papillomatous  growths  penetrating  the  cyst-wall. 
Direct  injury  from  blows,  falls,  careless  palpation  in  examina- 
tion, and  contraction  of  the  abdominal  wall  in  labor. 
Torsion;  see  twisting  of  the  pedicle. 
The  results  of  nqjture  are  as  follows: 

A  ruptured  parovarian  cyst  may  in  exceptional  cases  become  oblit- 
erated and  thereby  spontaneously  cured.  Cases  of  supposed  ovarian 
cysts  have  been  reported  as  cured  by  rupture  or  tapping,  but  it  is 
known  that  an  ovarian  cyst  cannot  be  cured  in  this  way;  the  tumors 
in  question  must  have  been  parovarian. 
Rupture  may  occur  into: 
Peritoneal  cavity,  most  frequent.  Small  intestine,  rare. 

Bladder.  Stomach,  rare. 

Vagina.  Fallopian  tube,  rare. 

Rectum.  Abdominal  wall,  rare. 

The  results  of  escaped  contents  and  sequels  of  rupture  are: 
If  a  parovarian  or  an  ovarian  cyst  containing  innocent  aseptic 
fluid  ruptures  into  the  abdomen,  the  fluid  may  be  absorbed 
through  the  peritoneum  and  eliminated  by  the  kidneys  without 
harm. 
If  rupture  of  a  papillomatous  cyst  takes  place  into  the  abdomen, 
the  cyst  contents  are  liable  to  form  secondary  papillomata  on 
the  peritoneum. 
The  contents  of  a  dermoid  cyst  may,  if  septic,  infect  the  peri- 
toneum, or  dermoid  elements  may  be  engrafted  on  the  peritoneum. 
The  colloid  contents  of  a  cyst  may  cause  peritonitis. 
The    contents   from   a   malignant    cyst    may   engraft   malignant 

disease  on  the  peritoneum. 
If  fluid  passes  by  rupture  into  a  hollow  viscus,  the  opening  may 
close  and  the  sac  refill,  or  the  opening  may  remain  and  trans- 
mit the  contents  of  the  viscus  to  the  sac;  thus  feces  and  gas  may 
escape  from  the  bowel  to  the  tumor  and  replace  the  tumor 
dulness  with  resonance  on  percussion;  or  urine  from  the  bladder 
may  fill  the  sac,  which  in  this  way  may  become  infected. 
The  pathological   results   of   rupture   will   vary   according   to   the 
condition  outlined  in  the  preceding  paragraphs  and  the  nature  of 
the  escaped  fluid.    The  accident  even  in  the  non-fatal  cases  is  apt  to 
be  marked  by  more  or  less  severe  peritonitis  with  adhesions.    A  mono- 
cyst  upon  discharge  of  its  contents  will  collapse.     A  polyc^'st  upon 
rupture  of  one  or  more  of  its  locuments  only  changes  its  form.    Rupture 
of  an  infected  cyst  into  the  peritoneum  is  usually  fatal   unless  the 
infection  is  cut  off  by  immediate  ovariotomy. 

Symptoms 

The  symptoms  of  ovarian  and  parovarian  tumors,  of  which  none 
is  pathognomonic,  are: 


OVARIAN  AND  PAROVARIAN  CYSTS  443 

1.  Nutritive  disorders;  intestinal  indigestion,  and,  in  many  cases, 

constipation. 

2.  Menstrual  disturbances;  not  very  significant: 
o.  Sterility;  not  invariable,  even  in  bilateral  cases. 

4.  Pregnancy  may  be  simulated. 

5.  Pains  from  peritonitis  not  uncommon. 
0.  Pressure-symptoms: 

(I.  ^'esical  and  rectal  tenesmus. 

b.  (Edema   of   vaii:iiia,   vulva,   and   lower  extremities  from 

pressure  on  iliac  veins. 

c.  Abdominal  pains. 

d.  Uterine  displacements. 

e.  Hemorrhoids. 

/.  Urinary  functions  disturbed;  albuminuria  associated 
with  pressure  on  renal  artery;  suppression  of  urine 
and  hydronephrosis  from  pressure  on  ureters.  Vesical 
irritation  and  cystitis  from  pressure  on  bladder. 

g.  Ascites  from  pressure  on  vena  cava  or  from  malignancy. 

h.  Pressure  on  thoracic  viscera  may  cause  most  distressing 
symptoms,  such  as  weakness  of  the  heart,  rapid  pulse, 
and  dyspnoea  so  extreme  that  the  patient  must  main- 
tain continuously  the  sitting  posture,  night  and  day; 
pressure  on  the  stomach  and  bowels  may  cause  nausea 
vomiting,  and  other  alimentary  disturbances;  pressure 
on  the  liver  and  bile-ducts  may  cause  catarrhal  jaundice. 

7.  Umbilical  hernia — occasional. 

8.  Atrophic  lines  on  abdominal  skin  when  cyst  is  large. 

9.  The    Facies    Ovariana. — This   is   a   peculiar   facial   expression, 

that  is  somewhat  diagnostic  of  the  disease  in  the 
later  stages.  It  is  difficult  to  describe,  but  once  seen 
is  remembered  easily.  The  natural  facial  expression  is 
modified  as  follows: 

a.  The  face  is  shrivelled,  elongated,   and  has  an  anxious 

and  careworn  expression. 

b.  The  nostrils  are  wide,  the  angles  of  the  nose  and  mouth 

are  drawn  down,  and  the  lips  are  thin. 

c.  The  cheeks  are  furrowed  and  the  face  is  marked  by  deep 

wrinkles. 

d.  The  space  between  the  eyelids,  and  the  bony  margin  of 

the  orbits  is  sunken  and  hollow. 

e.  The  whole  areolar  tissue  of  the  face  is  atrophied. 

/.  The  face  is  pale,  but  not  w^th  that  peculiar  leaden,  sallow, 

or  parchment-like  color  seen  in  malignant  diseases.^ 

The  facies  ovariana  is  quite  in  contrast  with  an  indescribable  and 

less  marked  full  and  flushed   facial   expression  known  as  the  facies 

uterina,  often  present  in  pregnancy  and  sometimes  in  cases  of  uterine 

tumors. 

'  Adaptation  from  Peaslee's  Ovarian  Tumors. 


444  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Diagnosis 

The  recognition  of  a  large,  uncomplicated  ovarian  cyst  is  usually 
not  difficult.    The  means  of  diagnosis  are:^ 

1.  Clinical  history. 

2.  Inspection 

3.  Palpation. 

4.  Percussion. 

5.  Conjoined  examination. 

6.  Measurement. 

7.  Exploratory  incision. 

The  physical  examination  by  inspection,  palpation,  percussion,  or 
conjoined  manipulation  requires  that  the  abdomen  be  exposed  and  that 
the  patient  lie  on  a  hard  couch  or  table,  preferably  the  latter. 

1.  The  Clinical  History  should  include  a  consideration  of  the  secondary 
changes  as  outlined  in  this  chapter.  It  also  includes  the  symptoms 
noted  in  the  foregoing  paragraphs,  the  age,  social  condition,  pregnancies 
(if  any),  family  history,  and  menstrual  history  of  the  patient. 

2.  Inspection. — If  the  tumor  is  small,  the  enlargement  will  be  most 
apparent  on  the  affected  side;  as  it  grows  larger  and  rises  out  of  the 
pelvis  the  swelling  will  be  greater  in  the  lower  part  of  the  abdomen 
between  the  pubes  and  the  umbilicus,  and  will  be  nearer  the  median 
line.  Abdominal  enlargement  from  a  unilocular  cyst  is  obviously 
more  symmetrical  than  from  a  multilocular  cyst.  With  declining 
strength  the  fades  ovariana  becomes  more  pronounced. 

3.  Palpation  will  show  usually  a  fluctuating  tumor;  if  small,  in  the 
pelvis;  if  large,  extending  into  the  abdomen.  The  mass  will  be  more 
distinct  on  the  affected  side.  The  degree  and  character  of  elasticity 
will  vary  with  the  tenseness  of  the  cyst  and  the  consistence  of  the 
contents.  A  greatly  distended  tense  sac,  especially  if  the  contents  are 
semisolid,  may  feel  like  a  solid  tumor. 

It  is  rare  to  find  solid  matter  predominating  in  an  ovarian  cyst. 
Large  masses  of  semisolid  matter,  and  small  nodules  of  very  hard  or 
bone-like  substance,  often  are  detected  by  palpation.  The  more  solid 
parts  are  found  rather  in  the  pelvis  than  in  the  abdomen.  The  different 
locuments  of  a  multilocular  cyst  in  some  cases  are  outlined  easily  by 
palpation.  The  cyst  sometimes  may  be  moved  from  side  to  side,  and 
up  and  down;  the  degree  of  mobility  will  depend  upon  its  size,  the  length 
of  the  pedicle,  and  the  extent  of  the  adhesions.  In  cases  of  very  thick 
or  rigid  abdominal  walls,  and  especially  of  small  tumors,  anaesthesia 
facilitates  the  examination. 

4.  Percussion. — The  tumor-sac,  with  its  contents,  occupies  the 
anterior  part  of  the  abdomen;  the  intestines  are  in  the  posterior,  lateral, 
and  upper  parts;  hence  the  maximum  dulness  on  percussion  will  be 
over  the  anterior  and  lower  portions  of  the  abdomen.  Since  the  cyst 
extends  from  the  pelvis,  the  dulness  will  be  continuous  from  the  abdo- 

'  In  the  diagnosis  and  differential  diagnosis  I  have  made  numerous  adaptations  from  the  classical 
work  on  ovarian  tumors  by  my  honored  friend  and  teacher,  the  late  Edmund  Randolph  Peaslee. 


OVARIAN  AND  I'AROVAIUAN   CYSTS  445 

incii  into  the  prl\  is;  it,  Iiowcnit,  will  cease  al)ru|)ll\  or  shade  oil'  into 
resonaiiee  and  tynii)aiiites  at  tiie  limits  of  the  tunu^r,  toward  tiie  sides 
of  the  abdomen  and  toward  the  diaphragm.  This  is  because  the  spaces 
above  and  to  the  sides  of  the  tumor  are  filled  with  intestine.  For  the 
relative  areas  of  dulness  and  resonance,  see  DilVerential  Diagnosis  of 
Ovarian  Cyst  and  Ascites.  The  location  of  the  cyst  does  not  chanj^e 
with  change  in  the  position  of  the  patient;  the  areas  of  dulness  corre- 
spond to  the  location  of  the  tumors,  and  are  constant. 

The  Percussion  ]Vave  usually  present  is  elicited  by  placing  the  finger- 
tijis  of  the  left  hand  to  one  side  of  the  tumor,  and  with  the  finger-tips 
of  the  right  hand  sharpl\-  tai)ping  or  thumping,  or  with  the  tliumb 
and  finger  snapping  the  other  side.  In  very  tense  cysts  and  in  cysts 
with  semisolid  contents,  like  dermoids,  the  wave  may  he  slight  or 
absent. 

5.  Conjoineii  Examination,  which  includes  ^aginal  and  rectal  touch, 
will  show  usually  the  relations  of  the  uterus  to  the  cyst.  The  impor- 
tance of  this  means  of  diagnosis  is  great,  for  any  cyst  of  pelvic  origin 
not  connected  with  the  uterus  is  almost  certainly  o^•arian  or  paro\arian. 
If,  therefore,  upon  vaginal  or  rectal  touch,  the  uterus  proves  to  be  healthy 
and  normally  mol^ile,  with  little  or  no  increase  in  length,  the  presump- 
tion is  in  favor  of  an  ovarian  tumor;  if,  upon  conjoined  examination 
with  one  or  two  fingers  of  the  left  hand  in  the  vagina  or  rectum,  and 
the  right  hand  over  the  abdomen,  the  uterus  can  be  made  out  distinct 
and  separate  from  the  cyst-tumor,  the  evidence  of  ovarian  tumor  is 
very  strong. 

In  very  exceptional  cases  of  ovarian  cyst,  however,  the  uterus  may 
be  enlarged,  drawn  up  out  of  the  true  pelvis,  immobile,  and  otherwise 
abnormal.  The  cyst  may  be  so  moulded  to  the  pehis  as  to  press  the 
uterus  forward  and  upw-ard  and  flatten  it  against  the  pubes.  The  tumor 
and  the  uterus  may,  through  adhesions  or  location,  be  nearly  or  quite 
inseparable  from  each  other;  such  conditions  are  very  indicati^"e  of 
uterine  tumors,  but  are  found  occasionally  with  ovarian  cysts.  See 
Differential  Diagnosis  of  Ovarian  Cysts  and  I'terine  Tumors. 

0.  Measurements, — If  the  tumor  is  of  considerable  size,  the  circular 
measurement  of  the  abdomen  is  increased.  The  distance  from  the 
anterior  superior  process  of  the  ilium  to  the  umbilicus  is  greater  on 
the  affected  side.  The  distance  from  the  pubes  to  the  umbilicus  is 
increased  relatively  more  than  that  from  the  umbilicus  to  the  ensiform 
cartilage. 

Diagnosis  of  Infection,  Twisting  of  the  Pedicle,  and  Rupture  of  the  Cyst 
wall  be  apparent  from  the  description  of  these  accidents  as  set  forth 
in  previous  paragraphs  of.  this  chapter. 

Diagnosis  of  Adhesions. — Adhesions  may  be  recognized,  though  not 
with  certainty,  by  the  following  signs: 

1 .  Immobility  of  the  tumor. 

2.  Sensitiveness  on  pressure  (peritonitis),  not  reliable. 

3.  Bands  of  adhesions  sometimes  may  be  felt  through  the  vagina 

or  at  the  sides  of  the  tumor. 


446  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Diagnosis  of  Malignancy. — The  physical  signs  of  malignancy,  not 
conclusive,   are   as  follows: 
1.  Nodular,  hard  surface. 


Figure  207 


•*K. 


D 


y/ 


E 


^■v    /^ 


.^^^ 


(.^3 


OVARIAX   AXn   PAnnVARIAX   CYSTS 


447 


2.  Ascites,  always  present  in  nialif^nancy,  seldom  nnicli  in  benign 

tumors. 

3.  Cachexia,  and  oedema  of  the  lower  extremities. 

4.  Metastasis. 

5.  Rapid    increase   of   growth    and    invcilvement   of   surrounding 

structures. 

The  distinction  between  follicular  cysts,  corpus  hiteum  cysts,  cyst- 
adenomata,  deniioid  cysts,  and  parovarian  cysts  has  been  outlined  in 
the  earlier  ])ara.o;raphs  of  this  chapter. 

Differential  Diagnosis. — The  pathological  conditions  that  have 
been  mistaken  for  ovarian  cysts  may,  for  convenience  of  description, 
be  divided  into  those  which  originate  in  the  pelvis  and  those  which 
originate  in  the  abdomen.  Among  the  more  important  of  these  condi- 
tions may  be  mentioned  the  following: 

Intrapelrnc  conditions,  which  may  be  mistaken  for 
ovarian  cyst 


Pregnancy 


Other    uterine    enlarge- 
ments    


I  Normal  gestation, 
Hydramnios, 
Tubal  pregnancy. 
Gestation  in  one  horn 
of  a  bifurcated  uterus. 


f  Myoma, 
I  Sarcoma, 

Carcinoma, 

Metritis, 

Hsematometra, 

Hydrometra, 

Pyometra, 

Physometra, 

Ovarian  hj'drocele. 

Hydatid  of  Morgagni. 


[Parametritis, 
Peh-ic  abscess, 
^  ,  .        "•(  Sactosalpinx, 

torj- enlargements      -   Peritonitis, 

[Pericsecal  abscess. 


Extra-uterine  inflamma- 


Abdominal  conditions,  which  may  be  mistaken  for 
ovarian  cyst 

Ascites. 

Encysted  ascites. 
Hydatid  cysts. 
Renal  tumors. 
Floating  kidnej". 
Pancreatic  cyst. 
Enlarged  liver. 
Mesenteric  cyst. 
Cysts  of  the  urachus. 
Enlarged  gall-bladder. 
Intestinal  tumors. 
Fatty  tumors. 


One  or  more  of  the  above  conditions  may  coexist  with  ovarian 
cystoma.  The  diagnosis  then  is  complicated,  difficult,  and  without 
exploratory  incision  may  be  impossible.  Before  taking  up  the  sub- 
jects outlined  in  the  foregoing  table  it  is  important  to  consider  the 
following  question: 

QuE.STiox  I. — Is  there  any  tumor  at  all  within  the  peritoneal  cavity? 

The  abdomen  has  been  opened  repeatedly  for  the  removal  of  a  sup- 
posed ovarian  tumor  when  no  tumor  of  any  kind  existed;  even  more 
frequently,  tapping  and  aspiration  have  been  done  when  no  fluid  was 
present.     One  author,  in  his  statistical  tables,  mentions  no  less  than 


EXPLAJTATIOX    OF    FiGUBE    207 

Ovarian  cysts  and  other  conditions  which  simulate  them. 

A,  ovarian  cyst  with  ascites;  the  ascites  causes  the  umbilicus  to  bulge. 

B,  ordinarj^  ovarian  cyst. 

C,  characteristic  shape  of  abdomen  in  neariy  sjinmetrical  myoma. 

D,  shape  of  abdomen  in  multiple  myoma  or  carcinoma. 

E,  cylindrical  shape  of  abdomen  in  ascites. 

F,  ascites  with  relaxed  abdominal  wall. 

G,  pendulous  abdomen  in  fat  woman. 

H,  pendulous  abdomen  from  advanced  ovarian  cyst :  woman  much  emaciated. 


448  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

twenty-one  cases  of  the  kind.'    The  following  conditions  may  give  the 
appearance  of  an  intra-abdominal  growth  when  no  such  growth  exists: 

1.  Fat  in  the  abdominal  walls. 

2.  Phantom  tumor. 

3.  Tympanites. 

4.  Fecal  accumulations. 

5.  Distended  bladder. 

6.  Dilated  stomach. 

1.  Fat  in  the  Abdominal  IFa//. — An  eminent  British  surgeon  once 
laid  open  the  abdomen  from  the  pubes  to  the  ensiform  cartilage,  only 
to  find,  instead  of  an  ovarian  cyst,  a  mass  of  subcutaneous  fat.  Similar 
blunders  have  occurred  repeatedly.  Such  an  error  at  the  present  day, 
however,  should  be  almost  impossible.  No  proper  signs  of  ovarian 
cyst  would  be  present  in  such  a  case.  The  mass  of  fat  in  the  abdominal 
wall  may  be  grasped  between  the  hands  and  isolated  from  the  abdomen. 
Vaginal  touch  would  also  yield  negative  evidence  of  a  tumor.  Great 
thickening  of  the  abdominal  wall  from  oedema  is  differentiated  by 
pitting  on  pressure. 

2.  Phantom  Tumor. — Some  hysterical  women  have  the  power  so 
to  contract  the  abdominal  muscles  as  to  force  up  the  tympanitic  intes- 
tines into  a  bunch,  and  in  this  way  to  make  an  apparent  abdominal 
enlargement  in  form  like  that  of  a  tumor.  Prolonged  firm  pressure 
with  the  palms  of  the  hands  usually  overcomes  the  muscular  con- 
traction. The  percussion  note  is  decidedly  tympanitic.  Ansesthesia 
completely  exposes  the  deception. 

3.  Tympanites. — The  extraordinary  blunder  occasionally  has  been 
made  of  mistaking  tympanites  for  an  abdominal  tumor.  This  has 
occurred  usually  when  the  evidences  of  percussion  and  palpation  were 
obscured  by  large  amounts  of  abdominal  fat.  Tympanites  will  be  known 
by  resonance  on  percussion,  absence  of  the  percussion  wave,  and  by 
the  negative  results  of  vaginal  touch. 

4.  Fecal  Accumulations  in  the  bowel  have  led  occasionally  to  the 
suspicion  of  an  ovarian  cyst.  The  history  of  constipation,  supple- 
mented by  palpation,  will  settle  the  diagnosis;  if  not,  acti^'e  catharsis 
will  remove  all  doubt.  Deep  pressure  through  a  thin  abdominal  wall 
or  through  the  vagina  causes  pitting  of  the  distended  bowel. 

5.  Distended  Bladder. — Retained  urine  may  accumulate  in  large 
quantity  until  the  bladder  appears  between  the  pubes  and  umbilicus 
as  a  distinct  fluctuating  tumor.  The  external  appearance,  on  inspec- 
tion, palpation,  and  percussion,  is  very  like  ovarian  cystoma.  The 
anterior  vaginal  wall,  however,  bulges  into  the  vulvar  orifice.  There 
is  an  almost  or  quite  continuous  overflow  of  urine  through  the  urethra. 
Hypogastric  pain  and  distress  are  urgent.  The  use  of  the  catheter 
will  settle  all  possible  doubt. 

6.  Dilated  Stomach. — The  author  personally  knows  of  one  case 
in  which   a  deservedly  eminent  surgeon  opened  the  abdomen  for  a 

1  John  Clary,  in  Ovarian  Tumors,  1872,  Peaslee. 


OVAh'f.W    AM)   /'AROVA/^lAX   CYSTS  449 

sui)|)os('(l  ()\;iriaii  (\\>t,:iii(l  IoiiikI  iiistciid  a  dilated  stoiiiacli.  'I'lic  con- 
dition ordinarily  wonid  l)C'  distinguished  from  cyst  hy  tlic  niaxiinuin 
enlar<i;eiiHMit  al)()\c  instead  of  below  the  unihilicus,  and  hy  resonance 
on  percussion  all  ()\er  the  tumor.  A  i)ositi\e  test  is  to  let  the  patient 
swallow  water  while  the  stethoscope  is  ])laced  oxer  the  tumor.  As  the 
water  reaches  the  stomach  a  gurgling-  sound  will  he  heard  clearly  all 
over  the  enlargement.  Inflation  of  the  stomach  through  a  tube  would 
cause  a  decided  t\mi)anitic  note  over  the  abdomen. 

(iiven  sufficient  evidence  that  there  is  a  tumor,  the  next  inquiry  is — 

Qlestiox  11.:    Is  the  enlargement  of  pelvic  or  of  abdominal  origin? 

If  not  of  pelvic  origin,  it  cannot  be  ovarian,  and  therefore  does  not 
come  within  the  scope  of  this  inquiry.  If  the  hand  cannot  be  inserted 
by  deep  firm  pressure  between  the  tumor  and  the  symphysis  pubis,  it 
is  inferred  that  the  timior  rises  from  the  pelvis;  if  vaginal  and  rectal 
touch  confirm  this  inference,  it  is  so  decided.^  The  pelvic  origin  of  the 
tumor  being  established,  the  next  inquiry  is — 

Question  111.:     Is  the  tumor  possibly  due  to  pregnancy? 

The  humiliation  of  atteniptinc/  to  remove  from  a  prec/ncuit  woman  an 
ovarian  tumor  which  does  not  exist  may  be  avoided  by  assuming,  until 
the  contrary  is  proved,  that  every  abdominal  enlargement  i)i  a  woman  is 
due  to  pregnancy. 

Differential  Diagnosis  of  Normal  Gestation  and  Ovarian  Cyst- 

Normal  gestation  |  Orarian  cyst 

1.  Enlargement  sudden,  rapid,  and  usually  ,  1.  Enlargement  gradual  and,  until  tumor  be- 
symmetrical.  comes  large,  asymmetrical. 

2.  Facies  natural  and  healthy.  2.   Facies  ovariana  in  later  stages. 

3.  Superficial  veins  of  abdomen  not  enlarged.  3.  Veins  enlarged.  CEdema  exceptional  and 
CEdema    of    ankles    not    uncommon    after   seven  only  after  one  or  two  years. 

months. 

4.  Fluctuation  not  distinct  unless  liquor  amnii  4.  Usually  very  distinct,  especially  in  mono- 
is  excessive.  cysts. 

5.  Menstruation  arrested.  5.   Not    usually    arrested    unless    late    in    the 

disease. 
G.   Vaginal  touch  detects  softening  and  appar-  6.  Uterus  imchanged  except  by  displacement, 

ent  shortening  of  the  cervix  and  enlargement  of  usu.illy  in  front  of  or  behind  the  cyst.     Tumor 

the  uterus.     No  extra-uterine  tumor.  extra-uterine. 

7.  Ballottement  gives  impulse  of  fcetus.  7.   Ballottement  gives  negative  results. 

8.  FcBtal  heart  sounds  after   twentieth   week.  <S.   None. 

9.  Foetal    movements    about    sixteenth    week.  'J.   None. 

10.  Enlarged    sebaceous    glands;    areola    about  10.  Rarely  imitated. 
nipples  darkened. 

11.  Tumor  has  developed  in  six  to  nine  months.  11.  Development  continues  two  to  four  years. 

12.  Rhythmic  contraction.  12.  Not  present. 

If  the  foetus  is  dead,  the  heart-sounds  and  foetal  movements  will, 
of  course,  not  be  present. 

Ovarian  cyst  and  pregnancy  not  infrequently  coexist.  The  diag- 
nosis then  is  made  by  the  clinical  history  of  both  conditions,  by 
palpation,  and  by  conjoined  examination. 

Hydramnios  is  an  excess  of  amniotic  fluid.  There  are  normally 
from  six  to  thirty  ounces;  this  amount  may  be  increased  enormously, 
giving  the  uterus  the  appearance  of  an  immense  cyst.  The  attempt 
has  been  made  occasionally  to  tap  or  remove  such  a  tumor  by  mistake 
for  an  ovarian  cyst. 

'  Adaptation  from  Peaslee's  Ovarian  Tumors.  •  Ibid. 


450 


TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS 


The  differential  diagnosis  of  hydramnios  and  ovarian  cyst  is  as 
follows: 

Hydramnios  Ovarian  cyst 


1.  Evidence  of  pregnancy. 

2.  Rapid  development. 

3.  Ballottement. 

4.  Distension  symmetrical. 


1.  Not  usual. 

2.  Less  rapid. 

3.  Absent. 

4.  Distension  more  on  one  side. 


Tubal  Pregnancy. — The  diagnosis  of  this  condition  will  be  found  in 
the  chapter  on  that  subject.  Unlike  ovarian  cyst,  it  gives  an  early, 
though  irregular,  history,  as  of  pregnancy.  Conjoined  examination 
before  rupture  shows  a  boggy,  fluctuating,  pulsating  tumor  at  the  side 
and  back  of  the  uterus.  After  rupture  the  tumor  is  less  distinct,  non- 
pulsating  and  non-fluctuating.  At  or  near  the  time  of  rupture  the 
endometrium  throws  off  a  modified  decidua  of  pregnancy.  The  symp- 
toms of  rupture  are  urgent;  they  are  those  of  pelvic  hsematocele,  and 
are  not  likely  to  be  mistaken  for  any  symptoms  of  ovarian  cyst  unless 
it  be  those  of  rupture  of  the  sac  or  twisting  of  the  pedicle. 

Gestation  in  One  Horn  of  a  Bifurcated  Uterus. — The  unilateral  loca- 
tion may  give  bicornate  pregnancy  the  appearance  of  an  ovarian  cyst 
or  of  a  myoma. 

Question  IV. :  Is  there  a  uterine  enlargement  due  to  other  causes 
than  pregnancy? 

The  pathological  conditions  suggested  by  the  question  are  these: 

Uterine  myoma.  Hsematometra. 

Uterine  sarcoma.  Hydrometra. 

Uterine  carcinoma.  Pyometra. 

Metritis.  Physometra. 


Differentiation  of  Uterine  Myoma  from  Ovarian  Cystoma^ 


Uterine  myoma 

1.  Slow  growtli. 

2.  Facial  expression  unchanged.  Face  may 
be  full  and  flushed;  later  pale  from  hemorrhage. 

3.  General  health  not  necessarily  impaired 
except  from  loss  of  blood  if  submucous  or  mural; 
may  be  painful. 

4.  Abdomen  often  asymmetrical  from  irregu- 
lar shape  of  tumor. 

5.  Abdominal  veins  not  usually  enlarged. 

6.  Action  of  kidneys  normal. 

7.  Usual  menorrhagia. 

8.  Elasticity,  not  fluctuation.  No  percussion 
wave. 

9.  Surface  firm  and  usually  lobulated. 

10.  Vaginal  touch  and  conjoined  examination 
show  tumor  dense  and  firm,  and,  unless  peduncu- 
lated, continuous  with  uterus.  Uterus  large  and 
heavy. 

11.  Uterine  cavity  much  elongated. 

12.  Uterus  moves  with  tumor. 

Exceptions. — A  subperitoneal  myoma  with  a 
long  pedicle  moves  independently  of  the  uterus, 
and  the  uterine  cavity  is  not  necessarilv  length- 
ened. If  the  myoma  has  degenerated  to  a  fibrocyst, 
there  will  he  more  or  less  fluctuation.  CEdema- 
tous  myomata  may  give  rise  to  apparent  fluctua- 
tion— pseudofluctuation. 


Ovarian  cystoma 

1.  Usually  more  rapid  growth. 

2.  Facies  ovariana  in  later  stages. 

3.  General  health  early  impaired  from  ema- 
ciation.    Not  painful. 

4.  Abdomen    more    symmetrical,     especially 
when  tumor  is  large. 

5.  Usually  enlarged,  especially  in  large  poly- 
cysts. 

6.  Kidneys  less  active. 

7.  Menstruation    unchanged    or    diminished. 

8.  Fluctuation     marked.       Percussion     wave 
marlced. 

9.  Surface   yielding;    in    monocysts,    regular; 
in  polycysts,  irregular. 

10.  Uterus  normal,  except  displacement  from 
pressure.  Tumor  compressible,  fluctuating, 
separate  from  uterus. 

11.  Not  materially  elongated.  (This  is  a  most 
important  diagnostic  point.) 

12.  Does  not  move  with  tumor.  _ 
Exception. — In  a  cyst  with  semisolid  contents 

fluctuation,    if    present,    is    indistinct,    and    per- 
cussion wave  is  absent  or  indefinite. 


1  Adaptation  from  Peaslee's  Ovarian  Tumors. 


OVARIAX   AM)   PAROVARIAX   CYSTS 


451 


Differentiation    nj   L  terinc    Sdrcm/Ki    (uitl   ('(irchioinu  from    Ocariuu 

Cyst 

The  relations  i)f  these  f:ro\vths  to  the  uterus  are  simihir  to  those  of 
myoma.  The  accompauNiiii;  tahuUited  statement  concerning  myoma, 
therefore,  in  the  main  apphes  to  malignant  growtlis.  Mahgnant 
uterine  tumors  (Htfer  from  myoma  in  these  particulars — viz.,  more 
pain,  great  tendency  to  early  ulceration  and  other  degenerative  changes, 
more  profuse  hemorrhages,  offensive  watery  or  bloody  discharge, 
cachexia,  ascites,  and  a  speedily  fatal  result. 

Figure  208 


Ovarian  hydrocele,  natural  size.     The  tortuous,  retort^.shaped  Fallopian  tube  connects  the  tumor 

with  the  uterus. 


Differentiation   of  Metritis  from    Ovarian    Cyst 

Metritis  gives  a  history  of  inflammation,  and  is  apt  to  be  associated 
with  parametritis,  salpingitis,  and  ovaritis.  The  uterus  is  never  en- 
larged to  more  than  two  or  three  times  its  normal  size,  and  in  form 
is  always  symmetrical.  Conjoined  examination  will  show  that  there 
is  no  extra-uterine  growth.  There  are  also  tenderness  on  pressure 
and  diminished  mobilitv. 


452  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Differentiation  of  HcBuiatometrd,  Ilydroiiietra,  Fyoiiietra,and  Physometra 

from  Ovarian  Cyst 

In  the  conditions  above  named  the  uterine  enlargement  is  always 
symmetrical,  and  the  uterus  whether  distended  with  blood,  serum,  pus, 
or  gas,  gives  a  greater  or  lesser  sense  of  fluctuation,  but  not  the  clear 
fluctuation  of  a  cyst.  See  Retained  Menstruation,  under  Congenital 
Malformations.  Examination  will  show  that  the  os  externum  or  the 
cervical  canal  at  some  point  is  closed.  Unless  the  Fallopian  tubes  also 
are  distended  the  enlargement  will  be  confined  entirely  to  the  uterus. 

Question  V.:  Is  the  enlargement  due  to  an  enormously  devel- 
oped hydatid  of  Morgagni,  or  to  ovarian  hydrocele,  or  is  it  possibly 
an  ovarian  cyst  communicating  with  one  Fallopian  tube,  that  is,  a 
tubo-ovarian  cyst? 

The  Hydatid  of  Morgagni  may  grow  to  such  considerable  size  as  to 
be  a  mechanical  irritant  and  require  removal.  The  diagnosis  of  such  a 
growth  is  only  possible  through  an  exploratory  incision. 

Ovarian  Hydrocele. — Ovarian  hydrocele  is  a  rare  and  curious  disease, 
in  which  the  dilated  Fallopian  tube  communicates  by  its  abdominal 
opening  with  the  cavity  of  a  cyst.  The  opening  is  usually  large  and 
circular.  According  to  Bland  Sutton,  the  formation  of  the  cyst  is  analo- 
gous to  that  of  hydrocele  in  the  male.  He  gives  evidence  to  show  that 
it  arises  in  a  tunic  of  peritoneum,  which  sometimes  invests  the  ovary 
as  the  tunica  vaginalis  covers  the  testis.  Ovarian  hydrocele  may 
suppurate,  and  may  then  easily  be  confounded  with  a  tubo-ovarian 
abscess.  It  has  been  confounded  with  tubo-ovarian  cj'St,  The  dis- 
tinctions between  these  two  cysts,  made  by  Bland  Sutton,  are  shown 
in  the  following  tabular  statement: 

Ovarian  hydrocele  Tubo-ovarian  cyst 

1.  Salpingitis   has    nothing    to    do    with    the  1.   Salpingitis  is  a  cause  of  the  communica- 
caiise,  although  it  may  be  present  as  a  compli-  tion  between  the  tube  and  ovarian  cyst, 
cation. 

2.  The  opening  between  the  tube  and  sac  is  2.  The  opening  is  variable  in  size,  and  usu- 
larfce  and  round  or  oval,  and  is  the  dilated  ab-  ,  ally  does  not  correspond  to  the  abdominal  os- 
dominal  opening  of  the  tube.  j   tium;   if   the   cyst  is   purulent — i.   e.,   if   it  is  a 

I  tubo-ovarian    abscess — the    opening    is    usually 
I   small. 

3.  The  tube,  not  large,  is  usually  tortuous,  3.  The  tube  is  usually  larger  and  not  tor- 
like  the  worm  of  a  retort.                                                     tuoiis. 

4.  There  is  apt  to  be  an  intermitting  dis-  j  4.  The  intermitting  discharge — salpingitis 
charge  of  fluid  from  the  tube  through  the  uterus.       profluens — not  common. 

— hydrops  tuboe  profluens. 

Question  VI.:  Is  the  enlargement  extra-uterine,  and  possibl}' due 
to  inflammation? 

This  question  suggests  the  following  conditions: 

Parametritis,  Pyosalpinx,  Peritonitis,  . 

Pelvic  abscess.  Hydrosalpinx,  Pericaecal  abscess. 

The  history  of  inflammation  and  the  close  relations  of  the  enlarge- 
ment to  the  uterus  will  aid  greatly  in  the  recognition  of  any  of  these 
diseases.  In  all,  except  possibly  hydrosalpinx,  there  will  be  tenderness 
on  pressure.  Sactosalpinx,  whether  the  tube  be  distended  with  serum, 
pus,  or  blood,  will  be  identified  usually  by  its  location  to  the  side  and 


0\  ARIAX   AM)   PAROVARIAX   CYSTS 


4o:i 


back  of  the  uterus,  but  more  especially  by  tlit-  irrejjuiar,  elongated, 
tortuous,  or  ovoid  form  of  the  mass.  A  pus-tuln-  is  much  more  likely 
to  be  adherent  than  an  ovarian  cyst  of  small  size.  A  parametric  abscess 
situated  in  the  l)road  li<;ament  is  always  continu(JUs  with  the  side  of 
the  uterus.  Suppuration,  anterior  or  posterior  to  the  uterus,  is  al.so 
inseparable  from  the  uterus.  Pericaecal  abscess  or  appendicitis  may 
be  suspected  from  its  location. 


r/ INTESTINAL',  ^\ 

resonance!  Z\ 
m 

c/i 


FiGUKE  209.  —  \reas  of  dullness  and  resonance  in  ovarian  cyst;  dulness  over  tumor;  resonance  over 
intestine  in  the  flank  opposite  to  the  side  on  which  the  tumor  has  developed.  There  would  be  no 
change  in  areas  of  resonanc'e  and  dulness  with  change  in  position  of  patient;  dulness  over  liver  in 
hepatic  region. 

Figure  210. — .Areas  of  resonance  and  dulne&s  in  ascites;  resonance  over  intestines:  hj-drostatic 
dulness  below  level  of  fluid  in  the  flanks;  dulness  over  liver  in  hepatic  region.  Constant  change  in 
areas  of  dulness  and  resonance  with  change  in  position  of  patient,  because  intestines  seek  high  level 
and  fluid  seeks  low  level. 

QuESTiox  yil.:  Is  the  tumor  of  abdominal  origin,  and  therefore 
not  ovarian  y 

A  large  ovarian  cyst  may  have  a  pedicb  so  long  as  to  permit  the 
entire  tumor  to  rise  out  of  the  pelvis  into  the  abdominal  cavity.  It 
may  even  be  possible  to  insert  the  hand  deeply  between  the  tumor 
and  the  symphysis  pubis.  Conjoined  \aginal  and  rectal  touch  may 
not  discover  the  pedicle,  nor  establish  the  pelvic  origin  of  the  cyst; 
it  is  sometimes,  therefore,  difficult  to  differentiate  such  a  cyst  from 
other  tumors  of  abdominal  origin. 

The  following  extrapelvic  pathological  conditions  ha^•e  been  mistaken 
for  ovarian  cvst : 


Ordinary  ascites. 

Encysted  ascites. 

Hydatid  cysts. 

Renal  cysts. 

Displaced  or  floating  kidney. 

Pancreatic  cvst. 


Enlarged  liver. 
[Mesenteric  cy.-<t. 
Cysts  of  the  urachus. 
Enlarged  gall-bladder. 
Intestinal  tumors. 
Fattv  tumors. 


454 


TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


Differential    Diagnosis   of   Ascites   and   Large   Ovarian   Cysts^ 


Ascites 

1.  Previous  history  of  visceral  disease. 

2.  Enlargement  comparatively  sudden. 

3.  Face  puffy;  color  waxy;  early  anaemia. 

4.  Patient  on  back,  enlargement  symmetrical; 
flat  in  front. 

.5.  Sitting  up.  abdomen  bulges  below. 

6.  Xavel  prominent  and  thinned. 

7.  Fluctuation  decidedly  clear,  diffu.se  through- 
out abdomen,  but  avoids  highest  parts  in  all 
positions,  and  always  has  a  hydrostatic  level. 

8.  Intestines  float  on  top  of  fluid;  hence  per- 
cussion gives  clear  tympanitic  note  over  the 
highest  parts  of  abdominal  ca\'ity,  and  dulness 
in  lowest  parts  for  all  positions — i.  e.,  areas  of 
resonance   and  dulness  change   with   position. 

9.  Vaginal  touch  detects  fluctuation,  bulging 
into  vagina. 

10.  Uterus  in  usually  prolapsed  location.  Size 
and  mobility  unchanged. 

11.  Hydragogues  and  diuretics  temporarily 
remove  the  fluid. 

12.  Fluid  light  .str.iw  color  and  thin.  Coagu- 
lates .spontaneously. 

Exceptions. — The  intestines  may  be  adherent 
to  the  po.sterior  part  of  the  abdominal  cavity, 
and  the  fluid  ma^-  therefore  be  in  the  anterior 
part,  or  the  amount  of  fluid  may  be  so  great  that 
the  intestines  held  back  by  mesenterj-  or  adhe- 
sion cannot  float  to  the  surface:  then  the  areaa 
of  resonance  and  dulness,  except  on  ver>"  deep 
percussion,  may  be  similar  to  those  of  a  cyst. 

Gas  in  the  colon  mav  produce  clearness  in  the 
flanks. 

Encysted  ascites — /.  e..  fluid  confined  to  a 
limited  part  of  the  abdomen  by  adhesions — may 
give  the  same  areas  of  dulness  and  resonance 
as  a  cvst. 


Ovarian  cyst 

1.  No  such  history. 

2.  Gradual. 

3.  Facies  ovariana.  Ansemia  absent  or  less 
marked  until  later  period. 

4.  Asymmetrical  until  tumor  is  quite  large; 
prominent  in  front. 

o.   Xo  appreciable  change. 
6.   Xavel  usually  unchanged. 
(.   Less   clear;   limited  to  cyst;   not  modified 
by  change  of  position.     X^o  hydrostatic  level. 

5.  X'o  change  in  areas  of  dulness  and  reson- 
ance with  change  of  position.  Dulness  over 
cyst.  Clear  resonant  note  in  all  parts  beyond 
cyst  limits — i.  e.,  in  flanks  and  toward"  the 
diaphragm. 

9.   Vaginal   fluctuation   less   clear   or   absent. 

10.  Uterus  displaced  fonvard  or  backward,  or 
laterally  by  pressure  of  cyst. 

11.  2\Iedicines  have  no  effect. 

12.  Fluid  light  or  dark  and  of  varj-ing  con- 
sistence; albuminous,  but  does  not  coagulate 
spontaneously;  may  contain  colloid  matter. 

Exceptions. — Flanks  may  be  dull  from  feces  in 
the  colon. 


Cyst  maj'  communicate  with  the  intestines 
and  be  filled  ndth  gas.  This  would  give  a 
tympanitic  note  all  over  the  cyst. 

The  cyst  may  be  small  and  glued  to  the  pos- 
terior part  of  the  abdominal  cavity  by  adhe- 
sions. The  intestine  might  then  be  in  front  of 
it  and  give  a  tympanitic  note  over  the  most 
prominent  part  of  the  enlargement. 


Ovarian  cy.st  and  ascites  may  coexist.  If  the  cyst  be  small  and 
the  patient  a  stout  woman,  the  diagnosis  without  exploratory  incision 
may  be  difficult. 

Differentiation  of  Hydatid  Cysts  from  Ovarian   Cysts 

Hydatid,  or  echinococcus,  cy.sts  are  sometimes  difficult  to  distinguish 
from  ovarian  tumors.  They  may  originate  either  in  the  pelvis  or  in 
the  abdomen.  Hydatid  cysts  of  pelvic  origin  may  be  in  the  broad 
ligament  or  immediately  beneath  the  uterine  or  pelvic  peritoneum. 
Hydatid  abdominal  cy.sts  may  originate  in  the  omentum  or  liver.  If 
of  abdominal  origin  and  of  small  size,  their  location  usually  will  prove 
them  to  be  extrapelvic,  and  therefore  not  ovarian.  The  qualifying 
word  "usually"  is  introduced  because  the  writer  once  encountered  a 
small  ovarian  cyst  adherent  to  the  liver.  The  pedicle  was  in  this  case 
very  slender  and  about  seven  inches  long.  In  palpation  of  hydatid 
cysts  a  peculiar  fremitus  sometimes  is  imparted  to  the  fingers. 

Large  abdominal  hydatid  cy.sts  may  extend  into  the  pelvis,  and, 
like  those  of  pelvic  origin,  closely  simulate  ovarian  disease.  These 
cysts  unless  inflamed   are   rarely  painful.     When  they   distend  the 


Adaptation  from  Peaslee's  Ovarian  Tumors. 


OVARIA.W  AXD  PAROVARIAN  CYSTS 


4:)."3 


abdomen,  thoy  j)n)jo(t  as  a  mass  of  small,  rounded,  tense,  elastic 
bodies;  the  individual  projections  are  smaller  than  those  of  ovarian 
cysts.  Fluctuation  is  distinct.  Suppuration  will  give  rise  to  signs  of 
an  abscess  in  addition  to  the  signs  of  hydatids. 

Definite  diagnosis  is  impossible  without  exploratory  incision.  The 
fluid  usually  will  show  the  characteristic  booklets.  It  is  slightly  alkaline 
or  neutral,  non-albuminous,  has  a  specific  gravity  of  about  lOU),  and 
contains  chloride  of  sodium.  Fragments  of  the  cluiracteristic  laminated 
lining  of  the  cyst  may  come  away  through  an  aspirator  or  trocar.' 

Degenerative  processes  may  cause  rupture  of  the  cyst  and  discharge 
of  its  characteristic  vesicles,  booklets,  or  membranes  through  the 
vagina,  rectum,  or  bladder;  the  diagnosis  is  then  clear.  Hydatid 
(\\sts  are  rare. 

FiGCRE    211 


Left  kidnev  in  the  hollow  of  the  sacrum:  the  renal  arten,-  and  vein  are  dragged  down  with  the  kidney 
producing  a  mechanical  disturbance  in  the  urinarj-  system  and  in  the  circulation  which  would  neces- 
sarily have  serious  results. 


Differentiation  of  Renal  Tumors  ajid  Ovarian  Cysts 

The  distinction  between  renal  tumors  and  other  abdominal  and 
pelvic  enlargements  is  often  extremely  difficult.  They  have  been 
repeatedly  mistaken,  not  only  for  ovarian  tumors,  but  as  well  for 
tumors  of  the  pancreas,  liver,  spleen,  intestine  omentum,  and  uterus. 

»  Sutton.     Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes. 


456 


TUMORS,    TUBAL   PREGNANCY,    MALFORMATIONS 


Without  an  exploratory  incision,  the  greatest  care  and  the  widest 
general  knowledge  may  be  inadequate  to  a  diagnosis.  The  enlarged 
kidney  has  been  found,  not  only  so  loose  as  to  occupy  almost  any 
location  or  position  in  the  abdomen  or  pelvis,  but  fixed  by  adhesions 
in  its  mal-location — for  example,  to  the  pelvic  brim  or  to  the  sacrum. 
In  such  cases  the  clinical  history  and  rational  signs — including  urinalysis 
— usually  will  give  evidence  of  renal  disease.  A  renal  cyst  may  be  hydro- 
nephrosis or  pyelonephrosis.    The  difi^erentiation  is  made  as  follows: 

Hyilrone-phrosis  Ovarian  cyst 


1.  Enlargement    unilateral    and    from    above 
downward.      Growth   fixed   in   region   of   kidney. 

2.  E.xpression  unchanged. 

3.  Growth  usually  slow. 

4.  Intestines  may  be  in  front  of  tumor. 


1.  Enlargement  at  first  unilateral;  later  sym- 
metrical and  from  below  upward.     No  fixation. 

2.  Facies  ovariana. 

3.  Growth  relatively  rapid. 

4.  Intestines  in  the  flanks  above  and  back  of 
tumor. 

5.  Fluid  albuminous;  no  calculi. 

6.  Tumor     usually     felt     by     vaginal     touch, 

7.  Urine  generally  normal. 
S.   Urine  flows  through  ureter  on  both  sides. 


Exception. — In  case  of  adhesions  the  cyst  may 
be  fixed. 


5.  Fluid     not    necessarily     albuminous;     may 
contain    calculi. 

6.  Vaginal  touch  negative. 

7.  Urine  may  contain  pus,  blood,  or  albumin. 
S.   Cystoscopy  shows  absence  of  urine  through 

ureter  on  affected  side;  except  there  may  be  sudden 
escape  of  urine  with  disappearance  of  tumor. 

Exception. — In  case  of  a  movable  kidney  the 
tumor  may  not  be  fixed. 

In  pyelonephrosis  the  symptoms  of  suppuration  will  be  present. 

Pancreatic  cyst,  enlarged  liver,  mesenteric  cyst,  cyst  of  the  urachus, 
enlarged  gall-bladder,  intestinal  tumors,  subperitoneal  or  omental 
fatty  tumors,  all  of  which  may  grow  to  large  size,  have  been  mistaken 
for  ovarian  cysts.  With  ordinary  care  and  skill,  however,  such  mis- 
takes are  not  likely  to  arise.  iVll  these  tumors  develop  from  above 
downward,  and  may  be  distinguished  easily  from  ovarian  cyst  by  their 
location  and  physical  characteristics.  Unlike  ovarian  cyst,  they  are 
usually  beyond  the  reach  of  vaginal  touch. 

Exploratory  Incision. — Finally,  in  cases  of  doubt,  the  question  may 
be  settled  by  exploratory  incision.  Indeed,  every  ovariotomy — yes, 
every  abdominal  section — should  begin  as  an  exploratory  incision.  Mr. 
Tait's  wise  caution,  already  quoted  in  connection  with  the  diagnosis 
of  pelvic  infiammation,  will  bear  repetition  here:  "One  may  easily 
turn  an  exploratory  incision  into  a  complete  operation,  but  it  may  be  a 
serious  matter  to  turn  an  incomplete  operation  into  an  exploratory 
incision." 

The  Prognosis,  without  operation,  of  ovarian  and  parovarion  tumors 
has  been  indicated  partially  under  Secondary  Changes  in  the  first 
part  of  this  chapter.  Multilocular  proliferating  cysts  and  papillomatous 
cysts,  if  not  removed,  usually  cause  death  in  about  three  years.  The 
causes  of  death  are: 

1.  Exhaustion    due    to    interference  .with    sleep,    nutrition,    and 

respiration. 

2.  Nephritis,  hydronephrosis,  uraemia,  cystitis,  pyelitis. 

3.  Peritonitis  and  intestinal  obstruction. 

4.  Suppuration  and  gangrene  of  cyst. 

5.  Rupture  of  cyst;  hemorrhages  from  any  cause. 
().  Impediment  to  labor. 

The  prognosis  with  early  ovariotomy  should  show  a  mortality  of  less 
than  1  per  cent. 


CHAPTER  XXX 
()\AHIOTO.MY 

The  jjeneral  |)riii('ii)les  which  ap])I\'  to  ovariotomN'  are  hiid  down  in 
Chaptors  III.,  VL,  Vll.,  and  VIll. 

Electricity,  incision,  and  drainage,  and  numerous  tlrugs  have  been 
tried  in  the  treatment  of  ovarian  cysts;  they  are  all  useless.  The  treat- 
ment is  summed  up  in  a  single  word — ovariotomy.  The  operation 
was  performed  first  in  1S09  by  Ephraim  ^McDowell,  of  Danxille,  Ky. 

Removal  of  Ovarian  Cyst 

The  subdivisions  of  the  subject  are: 

Preparatory  treatment. 

The  abdominal  incision. 

Emptying  and  delivering  the  cyst. 

Ligature  of  tlie  pedicle. 

Closure  of  the  wound. 

Drainage. 

After-treatment. 

Accidents  and  complications. 
The  Preparatory  Treatment  and  arrangements  for  the  operation, 
including  the  selection  of  sponges,   ordinary  instruments,  operating- 
table,  and  assistants,  have  been  outlined  in  the  General  Discussion  of 
Major  Operations,  Chapters  II.  and  VL 

The  Abdominal  Incision. — Ovariotomy,  except  for  small,  non- 
adherent cysts,  is  performed  by  abdominal  section.  The  incision, 
made  through  the  abdominal  wall  in  the  median  line  near  the  pubes, 
has  been  described  in  Chapter  VI.  Ordinary,  uncomplicated  ovariotomy 
requires  an  incision  not  more  than  two  or  three  inches  long. 

Cyst  fluid  may  be  perfectly  innocent,  or,  on  the  contrary,  may, 
from  suppuration  or  other  causes,  contain  infectious  matter.  The 
thick,  gelatinous  contents  of  colloid  cysts  and  the  contents  of  dermoid 
cysts  sometimes  are  infectious,  and,  if  brought  into  contact  with  the 
peritoneum,  may  be  dangerous.  In  order  to  avoid  such  contamination 
it  is  often  safer,  when  the  fluid  is  thought  to  be  infectious,  to  make 
a  long  incision  and  deliver  the  tumor  intact  without  attempting  to 
puncture  the  cyst  and  draw  off  the  fluid. 

Emptying  and  DeUvery  of  the  Cyst. — As  soon  as  the  peritoneal 
cavity  is  opened,  the  cyst,  usually  recognized  by  its  peculiar  blue  or 
g^a^^sh-white  color,  is  seen  directly  through  the  opening.  The  cyst 
being  exposed,  the  assistant  turns  the  patient  partly  on  the  side,  so 
that  the  abdomen  will  be  directed  toward  the  operator.  The  trocar^ 
28  (-157) 


Explanation  of  Plate  XXI 
OVARIOTOMY 

A.  Examining  the  Tumor. — The  abdomen  having  been  opened  by  an  incision  in  the 
median  line,  the  hand  is  introduced  into  the  peritoneal  cavity  in  order  to  determine  the 
presence  or  absence  of  adhesions,  and  to  break  up  any  slight  adhesions  which  may  be 
found. 

B.  Tapping  the  Cyst. — The  patient  is  on  the  right  side.  A  folded,  flat  gauze  sponge 
is  partially  introduced  into  the  peritoneal  cavity  and  held  by  the  left  hand  of  the  operator 
in  order  to  absorb  any  fluid  which  may  escape  from  the  cyst.  The  operator,  with  his 
right  hand,  plunges  the  trocar  into  the  cyst.  The  fluid  is  evacuated  through  the  trocar 
and  the  attached  rubber  tube  into  the  bucket  below. 


458 


PLATE    XXI 


PLATE    XXir 


Explanation  of  Plate  XXII 
Ovariotomy 

A.  As  the  fluid  passes  from  the  cyst  through  the  trocar  and  the  sac  begins  to  col- 
lapse, the  trocar  is  placed  in  the  hands  of  an  assistant,  and  the  operator  with  a  heavy 
long  forceps  in  each  hand  seizes  the  sac  on  either  side  of  the  trocar  at  points  a  and  fe, 
and  makes  steady  traction,  so  that,  as  the  sac  is  emptied  and  collapsed,  it  may  be 
drawn  out  through  the  abdominal  incision.  During  the  emptying  of  the  sac  it  is  seized 
successively  at  different  points  by  first  one  forceps  and  then  the  other  until  it  is  de- 
livered. The  delivery  of  the  sac  in  this  manner  by  traction  usually  would  be  rendered 
impracticable  or  impossible  by  adhesions;  see  A,  Plate  XXIII. 

B.  The  sac  has  been  emptied  or  nearly  emptied.  The  wound  in  the  sac-wall  made 
by  the  trocar  is  closed  temporarily  by  the  Nelaton  sac  forceps  e.  Forceps  a  and  h,  by 
which  the  sac  has  been  drawn  through  the  abdominal  incision,  are  hanging  upon  the 
cyst-wall.  The  pedicle  is  clamped  by  two  strong  forceps,  c  and  d,  which  then  are 
placed  in  the  hands  of  the  assistant,  and  the  pedicle  is  divided  between  them  by  means 
of  scissors  in  the  right  hand  of  the  operator,  while  his  left  hand  holds  the  tumor  steady. 


PLATE    XXIII 


Explanation  of  Plate  XXIII 

A.  If  the  sac  is  adherent  to  adjacent  structures,  the  adhesions  must  be  broken  up 
before  it  can  be  delivered  through  the  abdominal  wound.  Here  adhesions  are  shown 
between  the  sac  and  the  intestine,  and  are  being  broken  up  by  strong  pressure  with  the 
sponge  in  the  right  hand  of  the  operator  while  his  left  hand  holds  the  sac.  Verj- 
extensive  and  firm  adhesions  may  be  separated — sponged  off,  as  it  were — in  this  vray. 

B.  The  sac  has  been  delivered  through  the  abdominal  incision,  the  pedicle  clamped, 
and  the  tumor  removed.  Here  the  pedicle  is  shown  temporarily  clamp>ed  by  a  strong 
forceps.  This  forceps  corresponds  to  forceps  c,  Plate  XXII,  B.  Two  strong  ligatures 
en  masse  have  been  introduced  and  tied  one  on  each  side  of  the  pedicle.  These  ligatures 
control  the  ovarian  vessels.  The  black  and  white  dotted  line  shows  where  the  incision 
for  the  removal  of  the  pedicle  is  to  be  made. 

C.  The  pedicle  has  been  removed  by  an  incision  along  the  dotted  line  shown  in  B. 
The  ligatures  which  surround  the  ovarian  vessels  en  masse  are  being  held  taut  each  in 
a  pressure  forceps,  while  a  tenaculum  makes  downward  traction  on  the  centre  of  the 
cut  edge  of  the  broad  ligament.  This  shows  the  cut  edge  folded  and  being  united  upon 
itself  by  a  continuous  suture. 

D.  The  suture  uniting  the  wound  in  the  broad  ligament  is  completed.  For  a  full 
description  of  the  technique  of  this  procedure,  see  illustrations  of  removal  of  the  uterine 
appendages  in  Chapter  XX. 


460  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


Figure  212 


.4,  ovariotomy  trocar;  B,  retractor  for  keeping  abdominal  wound  open  durins;  the  operation  (two 
of  them  are  required);  C,  retractor  for  abdominal  wound;  D,  small  trocar  for  emptying  small  cysts; 
E,  N61aton's  cyst-forceps  for  drawing  out  the  empty  and  collapsed  cystr 


ovMaoroMY  loi 

with  ail  attached  ruMxT  tiilx-,  then  is  thriist  through  the  cNst-wall, 
and  the  fluid  is  drawn  into  a  l)ucki't  jjroxick'd  for  x\\v  ])urposc.  As 
soon  as  the  fhiid  hcuins  to  How  thi'  cyst-wall  is  seized  close  to  the  trocar 
with  th(>  Nclaton  or  other  lon<i'  t"()rcei)s — one  or  two  j)airs — and  as 
the  sac  eniptic^s,  the  collapsing-  walls  are  drawn  rapidl\'  through  the 
abdominal  woinul.  A  non-adherent  nionocyst  with  thin  walls  is  de- 
livered in  this  way  with  ^reat  ease.  In  ease  ol'  a  polyeyst,  the  point 
of  the  trocar  may,  witlioiit  complete  withdrawal,  be  thrust  successively 
into  one  compartment  after  another  until  all  are  emptied  and  the 
collai)se(l  sac  is  deli\ered.  The  ol)stacles  to  the  deli\-ery  of  the  sac 
are:  1.  Srrondari/  ri/sf.s.  2.  Sciiiisulid  ronictit.s  and  solid  porfions  of 
the  ci/.si.     ,').  Adiirsiou.s. 

1.  The  Secondary  Cysts  may  be  too  numerous  to  be  tapped  by  the 
trocar.  l)eH\ery  may  then  be  accompHshed  throucjjh  a  lartjer  incision, 
or,  the  trocar  ha\-in<2:  been  withdrawn,  one  or  two  fingers,  and,  finally', 
the  left  hand,  introduced  into  the  sac  breaks  up  the  partitions  between 
the  secondary  cysts — as  it  were,  eviscerates  the  cyst.  During  this 
manipulation,  in  order  to  prevent  escape  of  cyst-fluid  into  the  abdomen, 
the  forceps  in  the  right  hand  must  keep  the  opening  into  the  cyst- 
wall  drawn  well  outside  of  the  abdominal  incision. 

2.  Semisolid  Contents  found  in  dermoid  and  colloid  cysts  will  not  run 
through  the  trocar.  Often  tumors  are  partly  cystic  and  partly  solid. 
A  longer  incision  necessary  for  the  delivery  of  such  -non-collapsible 
tmuors  is  made  upward  with  scissors,  the  left  index-finger  being  used 
as  a  guide. 

3.  Adhesions,  which  are  the  most  common  obstacles  to  the  easy  de- 
livery of  the  sac,  may  be  parietal  or  visceral.  The  general  techniciue 
in  adhesions  is  described  in  Chapters  VI.  and  XX.  The  cyst  usually 
should  be  tapped  and  the  fluid  drawn  off  before  the  adhesions  are 
broken.  The  different  parts  of  the  sac  from  which  adherent  intestine, 
omentum,  and  other  structures  are  to  be  separated  may  usually  be 
brought  successively  into  the  opening,  and  the  adhesions  broken  until 
the  tumor  is  free.  If  this  cannot  be  done,  the  incision  is  lengthened 
and  the  adhesions  separated  in  situ.  In  loosening  the  adhesions  it  is 
well  to  secure  bleeding-points,  as  they  occur,  by  forcipressure,  or  torsion, 
or  fine  catgut  ligatures.  The  tumor  having  been  freed,  the  operation 
proceeds  as  already  described  for  non-adherent  tumors.  Plate  XXIII 
A,  shows  adhesions  being  separated  by  sponge  pressure. 

Ligature  of  the  Pedicle. — The  cyst  having  been  drawn  through  the 
alxlominal  incision,  the  pedicle  is  treated  as  shown  in  the  foregoing 
plates. 

Closure  of  the  Wound,  Drainage,  and  After-treatment. — These 
subjects  have  been  considered  fully  in  Chapters  VI.,  VII.,  and  ^TII. 

The  Accidents  and  Complications  are  such  as  may  occur  in  abdominal 
sections  performed  for  any  other  purpose. 

Extrusion  of  the  Bowel  during  operation  should  be  prevented  by 
the  assistants;  if  it  occur,  the  bowel  should  be  returned  immediately 
and  held  inside  by  broad  gauze  pads  or  towels. 


462  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Stripping  of  the  Parietal  Peritoneum  from  the  Abdominal  Wall,  under 
the  impression  that  it  is  an  adherent  cyst,  has  occurred  even  in  the 
hands  of  an  experienced  operator.  Peritoneum  thus  detached  is  apt 
to  slough;  and  therefore,  if  not  too  extensive,  should  be  removed  with 
the  tumor;  if  it  is  not  removed,  there  should  be  drainage  of  the  space 
between  the  detached  peritoneum  and  the  subjacent  structures. 

Rupture  of  the  Cyst-wall  and  Escape  of  its  Contents  are  harmless  if 
the  fluid  is  innocent;  unfortunately,  the  thin,  friable,  gangrenous 
cysts  that  are  apt  to  contain  infectious  fluids  are  the  ones  most  liable 
to  rupture.  The  clear  indication  after  rupture  is  to  sponge  thoroughly 
or  to  irrigate  the  cavity  with  normal  salt  solution — 0.8  per  cent.  If 
there  is  anticipation  of  rupture,  one  may  pack  sponges  around  and 
under  the  cyst  to  absorb  escaping  fluid. 

Injuries  to  the  Intestines,  Ureter,  or  Bladder  are  sometimes  unavoid- 
able. The  bowel  is  especially  liable  to  be  opened  in  breaking  up  adhe- 
sions. In  operating  deep  in  the  pelvis  the  bladder  or  ureter  may  be 
cut  even  by  a  careful  operator.  Injury  to  the  intestine  or  bladder 
should  be  repaired  immediately  by  suture.  If  the  ureter  has  been  cut, 
the  surgeon  will  have  recourse  to  one  of  the  following  procedures: 
1 .  The  cut  ends  may,  if  practicable,  be  reunited  by  end-to-end  approxi- 
mation after  the  method  of  Weller  Van  Hook.  2.  The  attempt  may 
be  made  to  turn  the  ureter  into  the  bladder.  3.  The  ureter  may  be 
brought  out  through  the  abdominal  wound.  4.  The  kidney  on  the 
affected  side  may  be  removed.     See  Chapter  XX. 

Foreign  Bodies  Left  Accidentally  in  the  Abdomen,  such  as  sponges, 
forceps,  and  other  instruments,  have  caused  numerous  deaths,  not 
only  after  ovariotomy,  but  after  other  abdominal  operations.  See 
Chapter  VI. 

Intestinal  Obstruction,  the  Principles  of  Drainage,  and  the  After-treatment 
have  been  presented  in  Chapters  VII.  and  VIII. 


Removal  of  Intraligamentous  Cysts 

Ovarian  and  parovarian  cysts  which  develop  between  the  folds 
of  the  broad  ligament  and  are  called  intraligamentous,  have  been 
described  in  the  previous  Chapter.  The  parovarian  cyst  is  easily 
peeled  out  of  the  broad  ligament.  The  papillomatous  ovarian  cysts 
may,  if  intraligamentous,  often  lie  deep  and  firmly  fixed  in  the  substance 
of  the  broad  ligament,  and  are  therefore  difficult  to  enucleate. 

Before  attempting  the  enucleation  two  ligatures  or  temporary  lock 
forceps  should  be  applied,  one  on  the  infundibulopelvic  ligament,  the 
other  on  the  uterine  end  of  the  broad  ligament.  The  first  cuts  off 
the  ovarian  artery  as  it  enters  the  pelvis;  the  second,  if  deeply  placed, 
cuts  off  the  utero-ovarian  anastomosis.  In  this  way  the  broad  liga- 
ment and  included  tumor  are  deprived  of  a  great  part  of  their  blood- 
supply,  and  the  troublesome  hemorrhage  sometimes  encountered  in  the 
removal  of  a  papillomatous  intraligamentous  cyst  therefore  may  be 


OVARIOTOMY  463 

avoided  measurably.  In  order  to  control  hemorrhage  it  may  be  neces- 
sary to  li^^ature  also  the  uterine  vessels,  or  even  to  remove  the  uterus. 

The  tinnor  may  be  removed,  according  to  its  depth,  in  one  of  two 
ways:  If  it  is  not  very  deep,  and  lies  rather  loosely  in  the  broad  liga- 
ment, the  ligament  and  cyst  sometimes  may  be  excised  and  removed 
together.  This  procedure  is  very  much  like  that  described  in  Chapter 
XX.  for  the  removal  of  the  uterine  appendages.  The  other  method 
is  that  of  enucleation,  and  as  indicated  above  may  be  extremely  diffi- 
cult and  hemorrhagic.  As  the  enucleation  proceeds  the  bleeding- 
points,  so  far  as  possible,  are  secured  by  fine  catgut  ligatures.  The  sac 
having  been  removed,  the  raw  bleeding  surfaces  between  the  folds 
of  the  broad  ligament  are  packed  temporarily  with  hot  gauze  sponges 
to  check  the  oozing.  The  redundant  portions  of  the  ligament  may  be 
trimmed  off  with  the  scissors,  the  edges  may  be  turned  in  and  united 
with  deep  interrupted  or  continuous  sutures.  If  the  ca\'ity  from 
which  the  sac  was  enucleated  is  too  large  to  be  obliterated  by  inver- 
sion and  suturing,  or  the  oozing  from  its  surface  is  uncontrollable,  an 
opening  may  be  made  from  the  bottom  of  the  cavity  close  to  the  uterus 
directly  into  the  vagina,  and  the  end  of  a  long  strip  of  gauze  may 
be  carried  through  this  opening  into  the  vagina,  the  cavity  packed 
full,  and  the  edges  of  the  broad  ligament  closed  over  the  packing. 
This  leaves  the  bleeding  part  entirely  covered  by  peritoneum,  renders 
the  raw  surfaces  extraperitoneal,  controls  hemorrhage,  and  provides 
for  drainage.  Care  to  avoid  the  ureters  is  necessary  in  the  enucleation, 
in  the  placing  of  deep  ligatures,  and  in  the  incision  into  the  vagina. 

The  gauze  drain,  which  is  the  same  as  that  described  in  Chapter 
XXIV.,  may  be  removed  through  the  vagina  in  two  or  three  days. 

Ovariotomy  during  Pregnancy 

An  ovarian  tumor  complicated  by  pregnancy  may  give  rise  to  the 
following  accidents:  1.  Twisting  of  the  pedicle.  2.  Abortion.  3. 
Obstruction  to  labor,  necessitating  Caesarean  section  or  ovariotomy 
during  labor.  From  these  and  other  possibilities  the  danger  of  labor 
to  child  and  mother  is  extreme.  Puncture  of  the  cyst,  as  a  temporary 
substitute  for  ovariotomy,  is  permissible  only  when  ovariotomy  is 
impracticable.  The  danger  of  both  puncture  and  ovariotomy  is  pos- 
sible sepsis  and  consequent  abortion  or  premature  labor.  In  the 
complication  of  pregnancy  the  necessity  for  an  early,  rapid,  gentle, 
aseptic  ovariotomy  is  apparent.  The  pedicle  always  contains  large 
vessels,  and  should  therefore  be  tied  with  special  care. 

Vaginal  Ovariotomy 

The  vaginal  route  offers  no  advantage  even  in  cases  of  small  pedun- 
culated non-adherent  cysts,  and  should  seldom,  if  ever,  be  preferred 
to  the  abdominal  route. 


CHAPTER  XXXI 

TUMORS  OF  THE  FALLOPIAN  TUBES,  BROAD  LIGAMENTS, 
ROUND  LIGAMENTS,   AND   URINARY  ORGANS 

TUMORS    OF    THE    FALLOPIAN    TUBES 

The  tumors  of  the  Fallopian  tubes  include  myoma,  adenoma,  adeno- 
myoma,  cysts,  carcinoma,  and  sarcoma. 

Myoma  of  the  tube  rarely  occurs,  seldom  obstructs  the  oviduct, 
and  is  commonly  too  small  to  be  of  clinical  significance.  One  case, 
however,  is  reported  in  which  the  tumor  reached  the  size  of  a  child's 
head.^  Salpingitis  isthmica  nodosa  and  tubercular  salpingitis  have 
been  mistaken  for  myoma  of  the  tube. 

Adenoma,  as  termed  by  J.  Bland  Sutton,^  or  papilloma,  as  first 
described  by  Doran,^  is  found  not  uncommonly.  The  growth  usually 
begins  as  a  small  papilloma  or  wart,  and  may  attain  the  size  of  a  large 
orange.  It  may  present  the  appearance  of  a  so-called  hydatid  mole, 
a  multiple  cyst,  or  a  cauliflower-like  growth.  A  frequent  complication, 
according  to  Sutton,  is  hydroperitoneum.  This  results  when  the 
abdominal  end  of  the  tube  is  open  and  the  secretion  passes  from  the 
tube  into  the  peritoneum.  When  the  abdominal  end  is  closed  and  the 
uterine  end  open,  there  may  be  a  discharge  through  the  uterus.  Adeno- 
mata frequently  undergo  malignant  degeneration;  early  removal  of  the 
tube  therefore  is  indicated. 

Adenomyoma  is  characterized  by  small  nodular  enlargements  of  the 
Fallopian  tube.  It  has  been  described  fully  by  Recklinghausen,  and 
later  by  Ries,  as  originating  in  the  remnants  of  the  Wolffian  body. 
The  various  nodular  enlargements  of  the  tube,  including  salpingitis 
isthmica  nodosa  and  adenomyoma,  may  be  caused  by  a  number  of 
pathological  conditions.  The  differential  diagnosis  between  them  must 
be  made  by  the  microscope.  They  cannot  be  distinguished  by  clinical 
examination. 

Cysts  of  the  tube  are  of  frequent  occurrence,  but  of  little  clinical 
importance.  Small  pedunculated  cysts,  known  as  hydatids  of  Mor- 
gagni,  are  often  to  be  found  at  the  fimbriated  extremity.  Numerous 
minute  cysts  with  thin  walls  are  seen  frequently  on  the  mucous  sur- 
face of  the  tubes. 

Carcinoma,  as  a  primary  growth,  is  very  rare  in  the  tube,  and,  when 
present,  is  usually  the  outgrowth  of  adenoma.     Secondary  carcinoma 

1  Sir  J.  Y.  Simpson.    From  System  of  Gynecology,  Playfair  and  Allbutt. 

2  Surgical  Diseases  of  the  Tubes  and  Ovaries. 

"  Transactions  of  the  Pathological  Society  of  London,  xxxi,   174.     Surgical  Diseases  of  the  Tubes 
and  Ovaries.     J.  Bland  Sutton. 

( 464 ) 


re  MORS  OF  THE  Rorxi)  ijcamext  4()5 

may  be  the  result  of  extension  from  the  o\ary  or  the  body  of  tiie  uterus. 
It  is  seldom,  if  ever,  secon(hiry  to  canc-er  of  the  cerNix  without  first 
involving  the  body  of  the  uterus. 

Sarcoma  of  the  tube  is  exceediuiirh  r;irc. 


TUMORS    OF    THE    BROAD    LIGAMENT 

Tumors  of  the  broad  ligament  include  myoma,  lipoma,  cystoma, 
carcinoma,  and  sarcoma. 

Myoma  and  Lipoma  are  pathological  curiosities  and  do  not  grow  to 
large  size.  The  other  growths  except  as  they  may  occur  by  extension 
are  equally  rare. 


TUMORS    OF   THE   ROUND   LIGAMENT 

Tumors  of  the  round  ligament  include  myoma,  fibroma,  cyst  or 
hydrocele,  sarcoma,  and  carcinoma. 

Myoma  and  Fibroma  are  rare,  but,  according  to  Coe,  are  more 
common  in  multipara  than  in  nullipara,  and  more  frequent  on  the  right 
than  on  the  left  side.  The  growth  may  be  intraperitoneal  or  extra- 
peritoneal. Myoma  is  commonly  pedunculated,  hard,  of  slow  growth, 
painless,  not  tender  to  pressure,  and  may  be  either  smooth  or  lobulated. 
During  pregnancy  it  may  increase  in  size  rapidly.  When  large,  it  may 
cause  pressure-symptoms;  if  extraperitoneal,  it  may  be  found  in  the 
inguinal  canal  or  in  the  labium  majus,  and  then  must  be  distinguished 
from  ovarian  and  omental  hernia,  enlarged  inguinal  glands,  and  cysts 
of  the  glands  of  Bartholin.  Ovarian  hernia  is  diflferentiated  from 
myoma  of  the  round  ligament  by  its  ovoid  form,  tenderness  on  pressure, 
possibility  of  reduction  on  pressure,  and  by  its  increase  in  size  during 
menstruation.  Omental  hernia  may  be  as  hard  as  myoma  and  impos- 
sible to  recognize  without  an  exploratory  incision.  Enlarged  inguinal 
glands  are  distinguished  by  the  history  of  infection,  by  the  lobulated 
outline,  and  by  the  presence  usually  of  more  than  one  enlarged  gland. 
Cysts  of  the  glands  of  Bartholin  are  distinguished  by  their  location. 
The  treatment  of  tumor  of  the  round  ligament  is  extirpation. 

Cyst  or  Hydrocele  is  supposed  to  be  developed  within  the  canal 
of  the  embryonic  round  ligament,  the  embryonic  ligament  being  hollow 
instead  of  solid.  It  may  appear  in  the  form  of  several  cysts,  or  of  a 
collection  of  fluid  either  within  the  inguinal  canal  or  at  the  external 
ring.  Schroeder  reports  a  case  in  w^hich  there  seemed  to  be  a  com- 
munication between  the  cyst  and  the  peritoneal  cavity;  at  least  the 
fluid  could  be  forced  by  pressure  into  the  abdomen.  The  condition 
is  a  rare  curiosity.  The  Differential  Diagnosis  is  from  myoma  of  the 
ligament  and  inguinal  hernia.  From  myoma  it  is  distinguished  by 
the  sense  of  fluctuation  and  by  exploratory  puncture.  From  hernia  the 
growth  is   distinguished   by   not   transmitting   impulse   on    coughing, 


466 


TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


by  failure  to  reduce  by  taxis,  and  by  fluctuation.      The  treatment  is 
extirpation  of  the  sac  and  direct  suturing. 

Sarcoma  and  Carcinoma  are  so  rare  as  to  be  of  interest  chiefly  as 
pathological  curiosities. 


TUMORS    OF   THE   URETHRA 

The  principal  varieties  of  urethral  tumor  are  caruncle,  mucous 
polypus,  condyloma,  wart,  carcinoma,  and  sarcoma.  The  most  fre- 
quent seat  is  the  meatus  urinarius.  Carcinoma  and  sarcoma  are  apt 
to  occur  by  extension  from  the  vulva  or  vagina. 

FlGUHE  213 


Pobijus  in  the  bladder. 


Urethral  Canmcle  is  a  growth  which  occurs  quite  frequently  in 
nervous,  irritable  women,  and,  although  no  age  is  exempt,  it  is  most 
frequent  near  the  menopause.  They  usually  are  of  the  granuloma, 
papilloma,   or  telangiectatic   (dilated  blood-vessels)   tj-pe.     Irritating 


TUMORS  OF   THE   URETHRA 


467 


discharges  from  above,  especially  the  discharges  of  gonorrhoea,  senile 
endometritis,  and  vnlv()\a,i,nnitis,  are  the  commonly  assigned  causes. 
This  growth  is  of  frequent  occurrence,  and  is  a  small,  soft,  red,  friable, 
hemorrhagic  mass  situated  usually  at  the  margin  and  on  the  vaginal 
side  of  the  meatus  urinarius.  It  may,  however,  be  anywhere  in  the 
urethra.  There  is  usually  a  previous  history  of  pelvic  disease.  There 
often  is  associated  great  sensitiveness  or  extreme  pain  on  urination; 
but,  according  to  Lange,  this  pain  is  due  not  so  much  to  the  growth 
itself  as  to  the  complications.  The  differential  diagnosis  from  Skene's 
glands  has  been  given  in  Chapter  XXI.  The  growths  may  be  differ- 
entiated from  other  tumors  in  the  same  region  by  the  constant  finding 
of  urethral  glands  in  the  caruncle,  although  the  structure  of  the  glands 


Figure  214 


Carcinoma  in  the  bladder. 


is  modified  frequently  by  hemorrhage,  round-cell  infiltration,  and  pro- 
lapse of  the  urethra  so  that  the  free  surface  of  the  caruncle  no  longer 
bears  cylindrical  nor  transitional  epithelium.  The  treatment  is  excision 
with  the  scissors  under  the  base  of  the  growth,  and  when  practical 
union  of  the  wound  by  suture.  Excision  may  require  dilatation  of  the 
urethra,  as  described  in  Chapter  III.,  or  Urethrotomy,  as  described  in 
Chapter  XXI.  The  actual  cautery,  though  commonly  used,  is  objec- 
tionable on  account  of  unreliability  and  because  of  its  destructive  and 
cicatricial  effects.  The  frequency  with  which  these  growths  return 
after  surgical  removal  is  due  undoubtedly  to  the  failure  of  operators  to 
treat  successfully  the  causative  complications. 

Warts,  Mucous  Polypi,  Carcinoma,  and  Sarcoma  follow  the  same 
principles  of  pathology,  diagnosis,  prognosis,  and  treatment  as  when 
thev  occur  in  the  vulva. 


468  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


TUMORS    OF    THE    BLADDER 

Tumors  originating  in  the  bladder  are  rather  rare.  They  occur  much 
less  frequently  in  the  female  than  in  the  male  bladder.  Benign  tumors, 
especially  if  polypoid,  are  removed  easily  through  an  artificial  vesico- 
vaginal fistula.  Hgemostasis  may,  if  necessary,  be  secured  by  leaving 
the  forceps  for  a  time  on  the  stump.  A  sessile  growth,  on  account 
of  its  inaccessibility  and  its  hemorrhagic  tendencies,  is  much  more 
difficult  of  removal.  Diagnosis  is  made  by  cystoscopy.  Malignant 
disease  is  in  a  majority  of  cases  an  extension  from  the  cervix  uteri, 
and  in  such  cases  the  treatment  is  wholly  palliative.  Small  carcinomata 
originating  in  the  bladder  may  be  removed  with  some  hope  of  cure. 
The  differential  diagnosis  of  vesical  tumors  is  from  calculi  and  other 
foreign  bodies  in  the  bladder.  Figures  213  and  214  show  polypus 
and  carcinoma  in  the  bladder. 


CHAPTER    XXXII 

ECTOPIC   PREGNANCY— EXTRA-UTERINE    PREGNANCY- 
OVARIAN  PREGNANCY— TUBAL   PRECJXAXCY 

Ectopic  pregiinncy  includes  all  forms  of  pregnancy  that  originate 
outside  the  uterus  ca\'ity.  Extra-uterine  pref/iidiicy  is  a  term  almost 
synonymous  witii  ectopic,  but  unlike  ectopic  would  not  include  an 
occasional  rare  form  of  gestation  occurring  in  a  rudimentary  horn  of 
a  bicornate  uterus,  nor  an  equally  rare  form  occurring  in  the  uterine 
wall.  Ovarian  pregnancy  is  a  pathological  curiosity  in  which  impreg- 
nation takes  place  and  gestation  continues  in  the  ovary.  Tubal  preg- 
nancii,  with  the  rare  exceptions  above  mentioned,  includes  all  forms 
of  gestation  that  originate  outside  the  uterine  cavity.  The  old  idea 
that  extra-uterine  pregnancy  could  originate  in  the  abdomen  is  obso- 
lete. Pregnancy  in  a  rudimentary  horn  of  a  bicornate  uterus  has  been 
considered  virtually  a  tubal  pregnancy.  Since,  therefore,  ectopic  gesta- 
tion is  almost  always  tubal,  this  chapter  will  be  confined  chiefly  to 
that  form. 

Tubal  pregnancy  is  not  infrequent.  Indeed,  pelvic  hsematocele, 
which  is  not  uncommon,  is  almost  invariably  the  result  of  it.  In 
thirty-fi\'e  hundred  general  autopsies  Formad  found  thirty-five  ectopic 
pregnancies,  or  1  per  cent.  This  is,  perhaps,  the  largest  percentage 
reported. 

Repetition  of  tubal  pregnancies  may  occur  in  the  same  individual. 
Both  tubes  may  be  simultaneously  pregnant.  Twin  tubal  pregnancy 
in  the  same  tube  and  concurrent  tubal  and  uterine  gestation  have  been 
reported.  There  is  no  absolute  rule  as  to  the  relative  frequency  of  the 
condition  on  either  side.  Tubal  pregnancy  has  been  reported  after 
extirpation  of  the  uterus,  the  tube  still  having  a  connection  with  the 
vagina.^ 

Etiology  of  Tubal  Pregnancy 

It  is  conceded  generally  that  in  at  least  a  large  proportion  of  cases 
normal  fertilization  of  the  ovum  occurs  in  the  Fallopian  tubes.  Sper- 
matozoa have  been  found  in  the  fimbriated  extremity  of  the  tube, 
and  it  is  probably  here  that  they  unite  normally  with  the  ovum.  The 
diameter  of  the  human  unimpregnated  o\'um  is  not  o\ev  two-tenths 
of  a  millimetre;  that  of  the  tube,  two  or  three  millimetres;  although 
after  impregnation  the  ovule  rapidly  increases  in  size,  yet  under  ordi- 
nary conditions  there  is  ample  time  for  it  to  pass  into  the  uterus  before 

1  Wendilcs.     Monatsschrift  fur  Geburtshiilfe  und  Gvndikologie,  lS9o.    Centralblatt  fiir  Gviijikologie, 
No.  4,  1S90 

(469) 


470  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

disproportionate  enlargement  takes  place.  The  question  of  the  size 
of  the  tube,  therefore,  is  not  very  pertinent  to  this  discussion. 

Tubal  pregnancy  is  common  after  long  periods  of  sterility.  This  is 
explained  possibly  by  the  fact  that  the  sterility  may  have  been  due  to 
chronic  salpingitis,  which,  by  thickening  of  the  tube  and  destruction 
of  the  cilia,  prevented  the  normal  passage  of  the  ovule  to  the  uterus 
and  at  the  same  time  favored  the  implantation  of  it  in  the  tube. 

According  to  Webster,^  tubal  pregnancy  is  explained  as  follows: 
In  the  earlier  type  of  mammalian  development  the  uterus  was  bicor- 
nate — that  is,  composed  of  two  horns,  of  which  the  Fallopian  tubes  in 
the  woman  are  mere  rudiments.  In  other  words,  the  uterus  consisted 
of  two  highly  developed  Fallopian  tubes.  In  some  women  even  now 
he  believes  there  is  a  structural  or  functional  reversion  to  the  ancient 
type.  According  to  this  theory,  the  stronger  the  tendency  to  rever- 
sion the  greater  the  liability  to  tubal  pregnancy.  This  harmonizes 
with  the  fact  of  repeated  tubal  pregnancies  observed  in  the  same 
individual. 

Peritonitic  adhesions  and  bands  obstructing  the  tubes  are  frequent 
in  ectopic  pregnancy;  but  whether  they  cause  the  morbid  condition 
or  result  from  it,  or  are  only  incidental,  is  uncertain. 

There  is  considerable  authentic  literature  on  the  transmigration  of 
the  ovum  from  the  ovary  of  one  side  to  the  tube  of  the  other.  Both 
clinical  and  experimental  examples  have  been  well  attested  in  which 
pregnancy  occurred  in  the  tube  when  the  ovary  on  that  side  was  absent. 
There  has  been  atresia  of  one  tube  and  tubal  pregnancy  in  the  other, 
but  with  the  corresponding  corpus  luteum  only  in  the  ovary  of  the  closed 
side.  All  this  proves  that  the  ovum  must  have  passed  across  the 
pelvic  cavity  to  the  tube  in  which  it  finally  lodged.  Tubal  pregnancy, 
therefore,  may  occur  under  most  unfavorable  conditions. 

The  following  is  a  summary  of  the  supposed  predisposing  causes, 
none  of  which  accounts  entirely  for  the  phenomena: 

1.  Inflammation  of  the  Fallopian  tubes  causing: 

a.  Desquamation  of  ciliated   epithelium  and  denuded  patches 

which  obstruct  the  ovum. 
h.  Loss  of  peristaltic  action  of  the  tube, 
c.  Cicatricial  contraction  in  the  tube. 

2.  Persistence  of  foetal  type — tube  long  and  tortuous,  with  small 

lumen. 

3.  New  formations  in  and  around  the  tube. 

4.  Torsion  of  the  tube. 

5.  Diverticula  in  the  tube. 

6.  Conditions  giving  rise  to  sterility  of  long  standing. 

Pathology  of  Tubal  Pregnancy 

Formation  of  Chorion,  Amnion,  Decidua,  and  Placenta.^ — During  the 
first  month  or  six  weeks  of  tubal  pregnancy  that  portion  of  the  tube 

1  Ectopic  Pregnancy.  ^  J.  Bland  Sutton,  in  Allbutt  and  Playfair's  System  of  Gynecology. 


ECTOPIC  PREGNANCY  471 

in  which  the  fertilized  ovum  is  lodged  becomes  thinner  and  very  vas- 
cular and  turgid.  The  mucous  membrane  becomes  stretched  and  its 
folds  elfaced.  The  changes  that  occur  in  the  fertilized  ovum  after 
impregnation  are  identical,  whether  it  be  in  the  tube  or  the  uterine 
cavity.  The  membranes  by  which  the  embryo  is  enclosed  are  similar 
to  those  in  intra-uterine  gestation.  These  membranes  can  be  studied  to 
advantage  in  the  so-called  tubal  moles,  which  are  similar  in  origin 
to  uterine  moles.  The  chorion  is  shaggy  with  villi,  and  resembles  in 
gross  and  microscopical  appearances  that  found  in  intra-uterine  gesta- 
tion. The  villi  appear  as  clusters  of  circular  bodies.  The  embryo 
lies  within  the  amniotic  cavity,  and  the  structure  of  the  amnion  and 
its  relations  to  the  embryo  and  chorion  are  almost  the  same  as  in 
intra-pregnancy. 

The  formation  of  the  placenta  in  tubal  gestation  differs  in  several 
particulars  from  one  developed  in  the  uterus.  In  normal  gestation 
the  uterine  mucosa  and  the  foetal  structures  both  contribute  to  the 
formation  of  the  placenta;  but  in  tubal  pregnancy  the  tubal  mucosa 
plays  a  very  insignificant  part,  the  tubal  placenta  being  derived  almost 
entirely  from  the  embryo. 

Contrary  to  Sutton,  Webster  has  demonstrated  a  decidua  in  the 
tube.  It  is  a  curious  fact  that  in  addition  to  this  tubal  decidua  a 
decidua  also  forms  in  the  uterus;  it  is  thrown  off  during  false  labor, 
or,  if  the  patient  goes  to  term,  is  expelled  later  in  small  fragments 
and  without  pain.  This  intra-uterine  decidua  has  all  the  elements  of 
a  decidua  of  normal  intra-uterine  pregnancy. 

Varieties  of  Tubal  Pregnancy 

Tubal  pregnancies  occur  at  the  uterine  end,  the  middle  region, 
or  near  the  abdominal  extremity  of  the  tube,  and  are  designated 
respectively : 

1.  Interstitial  pregnancy. 

2.  Isthmic  pregnancy. 

3.  Ampullar  pregnancy. 

The  subvarieties  will  be  noticed  in  describing  each  type.  The 
primary  classification  depends  upon  the  original  site  of  implantation 
not  upon  subsequent  accidents  of  developments  or  secondary  changes. 
A  normal  pregnancy  may  become  extra-uterine  by  rupture  of  the 
uterus,  as  in  a  case  reported  by  Leopold,^  but  that  does  not  make  it 
extra-uterine  in  the  sense  here  considered. 

1.  Interstitial  Tubal  Pregnancy. — This  is  by  far  the  least  frequent 
form.  Lodgement  of  the  ovum  takes  place  in  that  part  of  the  tube 
which  traverses  the  uterine  wall,  and  the  foetus  develops  in  a  cavity 
formed  in  the  substance  of  the  uterus.  The  foetus  thus  developed 
may  take  any  one  of  the  following  courses :  a.  It  may  pass  by  rupture 
into  the  uterus  and  be  expelled  as  by  ordinary  abortion,  b.  It  may 
gradually  be  extruded  into  the  uterine  cavity,  the  placenta  remaining 

1  Archiv  fiir  Gynakologie,  Ivii,  1896. 


472 


TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


in  the  horn  of  the  uterus,  and  go  on  through  normal  or  nearly  normal 
uterine  gestation  to  term — tfiibo-uterine  loregnancy  and  yarturition. 
c.  It  may  by  rupture  rarely  pass  outward  between  the  folds  of  the  broad 


Figure  215 


In  the  right  tube  isthmio  pregnancy,  about  third  month.  Embryo  with  unbroken  membranes 
protruding  through  the  ruptured  tube. 

In  the  left  tube  interstitial  pregnancy.  The  embryo  lies  in  the  uterine  wall  between  the  left  horn 
of  the  uterus  and  the  isthmus  of  the  tube. 

ligament  and  have  a  subsequent  history  precisely  like  that  to  be  de- 
scribed presently  under  isthmic  pregnancy  with  rupture  into  the  broad 
ligament,  or  into  the  abdominal  cavity.     Webster^  concludes  that  in 

Figure  216 


Ampullar  pregnancy.  Fimbriated  extremity  of  the  tube  closed  by  adhesions,  which  renders  tubal 
abortion  impossible  and  rupture  inevitable.  Obiserve  a  decidua  of  pregnancy  which  has  developed 
in  the  endometrium. 


some  cases  of  interstitial  pregnancy  the  ovum  develops  in  the  side  wall 
of  the  uterus,  in  a  diverticulum  formed  by  the  incomplete  fusion  of 
Mueller's  ducts,  which   sometimes   occurs   in   this   particular   region. 


'  Ectopic  Pregnancy. 


ECTOPIC  PREGNANCY  473 

Pregnancy  in  a  rndimentary  horn  of  the  uterus,  although  having  a 
pathology  of  its  own,  is  yet  not  unlike  tubal  pregnancy.  The  course 
and  outcome  of  interstitial  pregnancy  will  he  noticed  later  in  connection 
with  that  of  the  other  forms. 

2.  Isthmic  Tubal  Pregnancy  is  more  frecjuent  than  interstitial,  less 
frequent  than  ampullar,  pregnancy.  The  ovum  is  lodged  in  the  middle 
part  of  the  tube  and  there  is  generally,  before  rupture,  a  spindle- 
shaped  dilatation.  After  the  ovum  has  attached  itself  to  the  tubal 
wall  it  continues  to  develop.  Naturally  the  conditions  are  not  so 
favorable  as  in  normal  gestation;  the  tubal  walls  are  less  suited,  and 
contribute  less  fully  to  the  nourishment  and  development  of  the 
embryo  than  does  the  uterus  in  normal  pregnancy.  The  whole  tube 
becomes  extravascular,  turgid,  thinner,  and,  in  most  cases,  less  and  less 
resistant.  The  margin  of  peritoneum  around  the  ostium  abdominale 
thickens  and  forms  a  ring  about  the  fimbria?.  This  ring,  unless  the 
tube  ruptures  earlier,  by  the  eighth  w^eek  usually  closes  over  and  shuts 
the  tube.  The  development  of  the  embryo  in  the  tube,  so  far  as  the 
conditions  will  permit,  follows  the  same  course  as  in  the  uterus.  The 
foetus  may  remain  in  the  tube  and  die  before  maturity. 

The  hihe  may  rupture  and  partly  or  wholly  discharge  the  foetus  in 
one  of  four  directions:  1.  Into  the  abdominal  cavity.  2.  Into  the 
space  between  the  broad  ligaments.  3.  Into  a  space  formed  by  adhesion 
between  the  tube  and  ovary.  4.  Into  the  uterus,  in  rare  instances, 
partly  or  wholly. 

3.  Ampullar  Tubal  Pregnancy  if  left  to  itself  usually  terminates  by 
passage  of  the  embryo  into  the  peritoneal  caA'ity  either  through  the 
dilated  fimbriated  extremity  of  the  tube — tubal  abortion — or  through  the 
ruptured  tube — tubal  rupture.  Tubal  abortion  necessarily  occurs  while 
the  ostium  abdominale  is  still  open — that  is,  before  the  eighth  week. 
The  nearer  the  implantation  of  the  ovule  to  the  ostium,  the  greater 
the  liability  to  abortion.  In  this  accident  the  product  of  conception 
— sometimes  called  tubal  mole — is  discharged  with  free  hemorrhage 
through  the  still  open  ostium  into  the  abdominal  caA'ity.  The  hemor- 
rhage gives  rise  to  the  formation  of  intraperitoneal  pelvic  hsematocele. 
The  accident  may  be  fatal  from  shock  and  loss  of  blood,  or  the  patient 
may  recover.  In  some  cases  the  mole  lies  quiescent  in  the  tube;  and 
if  only  partially  detached,  it  gives  rise  to  repeated  and  dangerous 
hemorrhage.  The  false  uterine  decidua  usually  is  thrown  off  with 
uterine  hemorrhage  when  the  tubal  abortion  takes  place.  The  latter 
occurrence  may  be  masked,  as  it  were,  by  the  uterine  hemorrhage. 
Tubal  abortion  does  nor  occur  in  interstitial  and  is  rare  in  isthmic 
pregnancy;  after  occlusion  of  the  ostium  it  can  hardly  occur  even  in 
the  ampullar  variety. 

Tubal  Rupture. — Rupture  of  the  tube  may  occur  in  any  variety  of 
tubal  pregnancy  and  at  any  period.  The  muscular  layers  of  the  tube 
(myosalpinx)  at  first  undergo  hypertrophy,  but  soon  that  portion 
to  w^ich  the  placenta  is  attached  becomes  thinned,  and  the  bundles 
of  muscular  fibres  are  separated;  this  favors  early  rupture.  It  is  not 
29 


474  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

very  usual  in  the  first  month,  is  quite  hable  to  occur  in  the  second, 
and  rapidly  becomes  less  frequent  after  the  beginning  of  the  third, 
still  less  in  the  fourth.  It  may  be  due  to  direct  tension  on  the  tubal 
walls  from  the  growing  foetus,  but  is  brought  about  commonly  by  hem- 
orrhage between  the  ovum  and  the  sac.  Among  the  other  causes  are 
mechanical  violence  from  falling,  jumping,  digital  examination,  and 
coitus.  The  rupture  usually  takes  place  when  the  hemorrhage  begins, 
that  is,  at  the  placental  insertion.  The  foetal  membranes  are  not  neces- 
sarily involved  in  the  tear.  If  the  ovum  still  retains  its  placental  in- 
sertion, as  it  does  in  rare  cases,  it  may  continue  to  grow.  More  com- 
monly it  is  extruded  through  the  ruptured  tubal  wall  and  passes  into 
the  abdominal  cavity;  or  it  may  pass  downward  between  the  folds  of 
the  broad  ligament  or  into  a  cavity  formed  by  adhesions  between  the 
tubal  wall  and  the  ovary. 

Rupture  in  interstitial  pregnancy  may  be  either  into  the  abdomen, 
where  it  is  apt  to  be  rapidly  fatal  from  hemorrhage  and  shock,  or  into 
the  uterine  cavity,  where  as  above  stated  pregnancy  may  continue  as 
in  normal  gestation.  Rupture  into  the  uterus  may  occur  much  later 
than  the  fourth  month. 

If  the  foetus  in  ampullar  or  isthmic  pregnancy  is  not  entirely  cut 
off  by  rupture  or  abortion  from  its  nutritive  connections,  or  disorganized 
by  hemorrhage,  and  especially  if  the  rupture  is  into  the  space  between 
the  folds  of  the  broad  ligaments  or  into  a  tubo-ovarian  cavity,  gesta- 
tion may  go  even  to  full  term.  If  the  foetus  and  its  investing  mem- 
branes escape  into  the  general  peritoneal  cavity,  the  placenta  remain- 
ing in  the  tube,  it  is  possible,  though  rare,  for  development  to  continue. 

The  notion  that  a  free  embryo  can  escape  entire  and  ingraft  itself 
on  the  peritoneum  is  obsolete.  The  experiments  of  Leopold  on  dogs 
demonstrate  the  great  absorbing  power  of  the  peritoneum,  and  indi- 
cate that  no  organism  thus  introduced  could  survive. 

If  rupture  occurs  very  early  in  pregnancy,  hemorrhage  may  be 
less  severe;  but  after  the  first  month  it  is  apt  to  be  formidable  and  may 
cause  death  in  a  few  hours.  If  the  hemorrhage  is  slight,  we  have  the 
common  type  of  retro-uterine  haematocele,  which,  if  not  aggravated 
by  repeated  bleedings,  is  generally  encysted  and  gradually  absorbed. 
In  isthmic  and  ampullar  gestation  the  rupture  is  often  downward  be- 
tween the  layers  of  the  broad  ligament.  The  blood  is  then  poured 
out  into  this  confined  space.  The  natural  tendency  of  this  confinement 
is  to  check  the  hemorrhage.  The  blood  thus  accumulated  is  called  a 
broad-ligament  hgematoma.  The  more  gradual  the  rupture  and  the 
more  slight  the  hemorrhage,  the  less  will  be  the  general  and  local  dis- 
turbance. Under  such  conditions  the  embryo  and  its  envelopes  and 
placenta  will  have  a  better  chance  to  adapt  themselves  to  their  enlarged 
and  enlarging  quarters,  and  may  go  on  to  term. 

If  the  escaped  embryo  develops  in  a  cavity  formed  by  the  two  layers 
of  the  broad  ligament  and  the  outer  wall  of  the  tube,  the  pregnancy 
is  called  tuholigamentous.  As  the  foetus  develops  it  presses  aside  and 
displaces  other  organs,  the  layers  of  the  broad  ligament  become  com- 


KcToric  i'h'i:(;.\.\xcy 


475 


pressed  or  tliickciicd  jiiul  t'orin  adlR'sions  to  siiiToundiii^'  i)arts,  the  ])eri- 
toiieiiin  is  ])resst'(l  iii)\\ard  and  stripped  from  tlie  bladder  and  alxloiiiinal 
wall,  the  nterns  is  displaced  to  the  opposite  side,  and  according  to  the 
direction  of  pressuri'  npward  or  downward. 


lu^lKE    217 


Secondary  abdominal  pregnancy  after  term;  primarily  tubal.  The  orieinai  attachment  of  the 
placenta  may  be  seen  in  the  ruptured  tube.  After  rupture  the  embrjo  developed  outward,  and  be- 
came adherent  to  the  peritoneum.  Operation  at  St.  Luke's  Hospital  by  laparotomy,  ^lacerated 
child  removed.  The  contents  of  the  gestation  sac  were  purulent  and  extremely  fetid.  The  incision 
was  made  directly  through  the  abdominal  wall  into  the  sac  without  invading  the  general  abdominal 
cavity.     Recoverj-. 


If  the  placenta  is  situated  in  the  upper  part  of  the  tube,  so  that  it  is 
pressed  up  above  the  foetus  toward  the  abdomen,  forming  a  tubal 
placenta  prsevia,  the  danger  from  secondary  rupture  of  the  gestation- 
sac  into  the  abdomen  is  very  great;  such  an  accident  is  apt  to  be  fatal. 
If  the  placenta  is  situated  below  the  foetus  toward  the  mesosalpinx, 
and  pressed  down  upon  the  pelvic  floor,  this  danger  is  less  imminent; 
for  rupture  in  this  situation,  since  it  does  not  of  necessity  directly 
involve  the  placenta,  is  attended  with  less  hemorrhage  and  less  risk. 
For  a  further  description  of  pehic  haematocele  see  Symptoms  on  a 
following  page. 


476  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

Symptoms  of  Tubal  Pregnancy 

To  some  extent  the  symptoms  of  tubal  pregnancy  have  been  indicated. 
In  some  cases  the  menstruation  is  uninterrupted.  The  usual  signs  of 
pregnancy,  such  as  pigmentation,  fulness  of  the  breasts,  and  morning 
sickness,  may  be  present  or  absent.  During  the  first  eight  weeks  the 
ordinary  subjective  signs  of  pregnancy  usually  are  absent.  Slight 
uterine  hemorrhages  may  occur  at  irregular  intervals  from  the  beginning. 
Colicky  pains,  probably  due  to  uterine  contractions,  appear  toward  the 
end  of  the  second  month,  and  are  apt  to  continue  at  irregular  intervals 
throughout  the  whole  period  of  gestation.  The  signs  of  interstitial 
pregnancy  are  much  like  those  of  normal  uterine  gestation.  This  is 
explained  by  the  nearness  of  the  gestation-sac  to  the  endometrium. 

When  tubal  pregnancy  goes  on  beyond  the  fourth  month  the  external 
sign  of  asymmetrical  enlargement  in  the  abdomen  begins  to  appear. 
The  pressure-symptoms  are  much  like  those  of  uterine  pregnancy. 
In  tuboligamentous  pregnancy  there  is  exaggerated  pressure  on  the 
pelvic  organs.  Finally  the  usual  signs  of  foetal  life  are  present,  and  in  the 
latter  months  of  tubal  pregnancy  painful  foetal  mo\ements  are  common. 

The  pains  of  spurious  labor  resemble  those  of  normal  parturition, 
and  are  sometimes  very  deceptive.  They  may  be  slight  or  severe. 
Cases  are  recorded  in  which  they  continued  for  days  and  even  weeks, 
or  recurred  irregularly  for  long  periods.  Cases  have  been  reported  in 
which  the  sac  ruptured  into  the  vagina  at  the  time  of  spurious  labor 
and  the  child  was  delivered  by  the  natural  passage.  Rupture  into 
the  intestine  with  consequent  expulsion  of  the  foetus  through  the  bowel 
has  been  reported.    This  could  occur  only  in  the  earlier  weeks. 

Pelvic  HoBmatocele  is  an  accumulation  of  blood  in  the  pelvis  conse- 
quent upon  rupture  of  a  blood-vessel;  in  rare  instances  it  may  be  due 
to  traumatism  or  to  rupture  of  a  vessel  from  disease  of  the  vessel,  or  to 
accumulation  of  menstrual  blood  in  the  presence  of  an  atresia  of  the 
lower  genital  tract  or  to  hemorrhage  from  corpus  luteum;  but  in  the 
vast  majority  of  cases  it  is  the  result  of  tubal  abortion  or  tubal 
rupture,  and  is  therefore  an  accident  of  tubal  pregnancy;  in  fact,  the 

Explanation  of  Figures  218  to  224' 

FiGTJEE  218. — Side  view.  Pregnancy  complicated  by  hsematocele  of  both  broad  ligaments;  blood- 
clot  posterior  and  to  either  side  of  the  uterus,  crowding  the  cervix  forward. 

Figure  219. — Retro-uterine  hsematocele  extending  into  both  broad  hgaments,  the  mass  on  the 
one  side  rising  much  higher  than  on  the  other,  so  that  accumulation  of  blood  feels  to  the  touch  like 
two  distinct  masses  closely  set  together  and  sharply  rounded  above  and  at  the  sides.  _ 

Figure  220. — Front  view.  Hsematocele  of  left  broad  ligament  extending  anterior  to  the  uterus; 
felt  as  a  hard  tumor  in  the  left  vaginal  vault  close  to  the  uterus;  easily  felt  through  the  vagina  and 
in  the  left  inguinal  region. 

Figure  221. — Retro-uterine  hsematocele  lifting  the  peritoneum  high  out  of  the  cul-de-sac  of 
Douglas,  and  extending  into  both  broad  ligaments.     Easily  felt  on  vaginal  and  abdominal  palpation. 

Figure  222. — Front  view.  Hsematocele  in  both  broad  ligaments  extending  in  front  of  the  uterus; 
tumor  larger  on  the  right  side  than  on  the  left,  and  divided  on  the  left  into  two  segments.  The  mass 
on  the  left  side  communicates  with  that  on  the  right,  high  up  in  front  of  the  cervix.  Uterus  pushed 
back  to  the  posterior  wall  of  the  pelvis. 

Figure  22.3. — Side  view.  Retro-uterine  hsematocele,  not  extending  to  the  sides  of  the  pelvis. 
Mass  felt  between  the  uterus  and  rectum,  Ufting  the  peritoneum  out  of  the  cul-de-sac  of  Douglas  and 
crowding  the  uterus  forward. 

Figure  224. — Front  view.  Hsematocele  of  the  left  broad  ligament,  lying  close  to  the  uterus;  easily 
felt  by  vaginal  touch  and  by  palpation  over  the  left  iliac  region.  Crowds  the  uterus  forward  and  to 
the  right. 

1  Redrawn  from  Kuhn. 


EC  Tone   PREd.WWCY 


477 


FiGCBE  218 


Figure  221 


FlGUEE  220 


FiGUEE  224 


478  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

symptoms  of  tubal  abortion  and  rupture  are  those  of  pelvic  hsematocele. 
There  are  no  premonitory  signs.  Small  hemorrhages  may  give  rise 
to  no  marked  subjective  symptoms;  even  large  accumulations  of  blood, 
if  free  in  the  peritoneal  cavity,  may  cause  little  or  no  pain.  When  the 
blood  is  poured  out  into  confined  spaces,  such  as  the  space  between  the 
folds  of  the  broad  ligaments,  the  subjective  symptoms  which  are  due 
to  the  tearing  of  the  tube  and  the  ligament  are  distressing  and  over- 
whelming to  the  patient. 

There  is  sudden  and  excruciating  pain  all  over  the  abdomen,  and 
especially  about  the  pelvis;  then  come  nausea,  vomiting  of  bile,  cold 
extremities,  bathing  of  the  skin  in  cold  sweat,  pinching  of  the  features, 
rapid  and  weak  pulse,  tenesmus,  and  irritability.  In  serious  cases  the 
shock  will  be  as  great  as  in  Asiatic  cholera;  the  pain  out-balances  every 
other  symptom.  The  tissues  are  being  literally  torn  asunder.  Such  a 
scene  can  never  be  forgotten.  The  woman  tosses  to  and  fro  and  stains 
the  bedclothing  with  vomitus.  The  bloodless,  pinched  features,  the 
bloodshot  eyes  starting  from  their  sockets,  the  twitching  of  the  facial 
muscles,  the  clinching  of  the  fingers,  the  piercing  shriek,  the  agonized 
bearing-down  movement,  as  if  the  woman  would  drive  the  contents 
of  her  body  from  her,  all  combine  to  make  upon  the  memory  an  indelible 
impression.  These  symptoms  may  subside  and  convalescence  may  be 
established,  with  absorption  of  the  clot;  or,  on  the  other  hand,  fresh 
hemorrhage  and  acute  anaemia  with  profound  collapse,  or  death,  may 
occur  suddenly. 1 

The  symptoms  are  much  more  pronounced  in  tubal  rupture  than  in 
tubal  abortion.  If  the  abortion  is  complete — that  is,  if  the  ovum  and 
its  envelopes  are  thrown  out  completely — the  hemorrhage  may  be  com- 
paratively slight  and  may  be  walled  in  by  adhesions;  under  such  cir- 
cumstances slow  recovery  may  take  place.  In  this  way  many  cases 
of  pelvic  hsematocele  recover  without  operation.  Such  results  are  prob- 
ably more  common  in  the  very  early  stages  of  tubal  gestation  than 
generally  is  supposed.  In  fact,  many  such  cases  are  unrecognized. 
There  is,  indeed,  a  possibility  of  moderate  and  gradual  hemorrhage 
without  pronounced  symptoms.  In  a  very  large  proportion  of  cases, 
however,  the  abortion  is  incomplete,  and  a  portion  of  the  ovum  or  its 
envelopes  is  left  attached.  Repeated  hemorrhages,  with  severe  abdominal 
pain,  may,  after  days  or  weeks  of  suffering,  unless  relieved  by  operation, 
end  in  collapse.  If  the  progress  of  the  case  is  more  rapid,  the  symptoms 
closely  resemble  those  of  intestinal  or  gastric  perforation  and  excessive 
hemorrhage  combined.  Hsematocele  at  first  may  be  unrecognized. 
If  the  bleeding  be  excessive,  the  early  sense  of  fulness  on  percussion  and 
palpation  gives  way  later  to  the  localized  signs  of  a  contracted  clot. 

The  hemorrhage  from  tubal  abortioh  is  much  less  than  from  tubal 
rupture. 

As  already  stated,  hemorrhage  into  the  space  between  the  folds  of 
the  broad  ligament  is  confined,  and  therefore  limited.  If  the  force  is 
sufficiently  strong  to  cause  secondary  intraperitoneal  rupture — that  is, 

'  Adaptation  from  Emmet. 


ECTOPIC  PREGNANCY  479 

riii)turt'  from  the  interior  of  the  lit(ament  to  the  peritoneum — there 
will  he  f^reat  danjier  of  acute  hemorrhage  and  collapse.  If  the  hlood 
is  confined,  vesical  and  rectal  tenesmus  and  other  symptoms  due  to 
tearing;  and  i)ressure  may  overwhelm  tlii'  ijatient. 

Diagnosis  of  Tubal  Pregnancy 

In  the  early  period  of  tuhal  j)re,t,niancy  there  are  no  certain  means 
of  diagnosis.  The  patient  may  ha\e  noticed  no  irre<i:ularity  in  her 
physiological  life,  and  may  ha^'e  been  utterly  unaware  of  her  condition 
until  the  occurrence  of  rupture  or  abortion.  This  is  especially  likely 
to  be  the  case  when  the  abortion  or  rupture  occurs  very  early  after 
impregnation.  Usually,  however,  it  occurs  between  the  fourth  and 
ninth  weeks;  during  this  time  certain  anomalies  already  mentioned, 
such  as  irregular  menstruation  or  pain,  may  have  attracted  attention 
and  led  to  the  discovery  of  an  enlarged  tube.  It  is  a  significant  fact 
in  diagnosis  that  tubal  pregnancy  often  occurs  after  long  periods  of 
sterility.  The  musculature  of  the  uterus  undergoes  hypertrophy;  the 
organ  may  enlarge  to  the  size  of  the  second  or  third  month  of  preg- 
nancy, and  then  to  some  extent  diminish.  If  the  tubal  pregnancy 
is  interrupted  by  abortion  or  rupture,  the  uterus  generally  at  the  same 
time  throws  off  the  decidua  with  a  bloody  discharge.  This  spurious 
labor  may  occur,  however,  at  any  time,  and  always  does  occur  at  some 
time  in  the  course  of  the  gestation.  The  microscopical  finding  of  this 
cast-off  decidua  together  with  the  history  of  tubal  pregnancy  is  strongly 
diagnostic.  In  the  later  periods  of  gestation  many  of  the  usual  signs 
of  pregnancy  are  modified  and  distorted  by  abnormal  conditions. 

The  diagnosis  may  be  considered  with  reference  to  three  groups 
of  cases: 

I.  Late  cases  in  which  neither  tubal  rupture  nor  tubal  abortion  has 
occurred  and  in  which  gestation  is  progressing  or  has  progressed  to 
term. 

II.  Early  cases  in  which  neither  tubal  rupture  nor  abortion  has 
occurred. 

III.  Early  cases  in  which  tubal  rupture  or  abortion  has  occurred. 
I.  Late  cases  in  which  neither  tubal  rupture  nor  abortion  has  occurred, 

and  in  which  gestation  is  progressing  or  has  progressed  to  term,  may 
be  recognized  by  the  following  characteristics: 

1.  Uterus  enlarged  to  the  size  of  two  months  pregnancy. 

2.  Formation  of  a  tumor  at  one  side  of  the  uterus,  which,  like 

the  uterus  in  normal  gestation,  gradually  increases  in  size, 
although  the  size  of  the  mass  does  not  always  correspond 
strictly  to  that  of  normal  gestation. 

3.  As  gestation  progresses  the  fcetus  may  be  palpated  externally. 

The  fcptal  heart-tones  become  distinct  at  about  the  same 
time  as  in  normal  pregnancy. 

4.  Intermittent  false  labor  at  nine  or  ten  months,  followed  })y 

cessation   of  circulation   in   the  placenta   and   death  of  the 


480 


TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


child,  and  finally  by  marked  diminution  in  the  size  of  the 
tumor. 
5.  General  sepsis  from  absorption   of  decomposing  products   of 
gestation  in  most  cases. 

II.  Early  cases  in  which  neither  tubal  rupture  nor  abortion  has 
occurred  may  be  diagnosed  by  the  following  signs: 

1.  Cessation  of  menstruation  for  one  or  two  months,  and  other 

signs   of   pregnancy,    such   as    nausea,    mammary   changes, 
and  venosity  of  the  vulva  and  vagina. 

2.  Ovoid  mass,  corresponding  in  position  to  the  right  or  the  left 

tube — not  very  sensitive  to  pressure. 

3.  Slight  intermittent  contractions  of  the  mass — not  always  felt. 

4.  Death  of  the  foetus  in  some  cases  without  tubal  rupture  or 

abortion  may  be  followed  by  absorption  of  the  amniotic 
fluid,  with  rapid  decrease  in  the  size  of  the  tumor. 

III.  Early  cases  in  which  rupture  or  abortion  has  occurred  are 
characterized  by  symptoms  the  same  as  those  of  group  II.,  followed 
by  sudden  onset  of  extreme  pelvic  pain,  evidences  of  acute,  alarming, 
and  sometimes  fatal  hemorrhage  and  sudden  appearance  of  a  pelvic 
tumor — hsematocele 

The  radiograph  often  is  a  means  of  positive  diagnosis  The  more 
advanced  the  gestation  the  more  clear  uill  be  the  picture. 

Differential  Diagnosis. — The  following  outlines  will  enable  the  reader 
to  distinguish  tubal  pregnancy  from  numerous  conditions,  for  which 
it  sometimes  is  mistaken. 


Ruptured  tubal  pregnancy.     Hmmatocele 

1.  No  initial  history  of  infection. 

2.  Great  rapidity  of  pulse. 

3.  Temperature  at  first  subnormal,  later  may 
be  elevated. 

4.  Pain   excruciating,    but   subsides   after   few 
hours. 

5.  Symptoms  of  hemorrhage: 

a.  Sudden,  acute  anaemia. 
h.  Weak,  rapid  heart. 

c.  Dyspnoea. 

d.  Sighing  respiration. 

e.  ]\'Iay  be  syncope. 

Ruptured  tubal  pregnancij.     Hmmatocele 

1.  History  of  pregnancy. 

2.  Sudden  onset. 

3.  Hemorrhage  may  cause  collapse. 

4.  Temperature  normal  or  subnormal  at  first. 

5.  Usually  mass  soft;  later  hard. 

6.  Fever    may    finally    follow    appearance    of 
hsematocele. 

7.  Uterine  decidua. 

8.  No  leucocytosis  at  time  of  rupture. 

Ruptured  tubal  pregnancy.     Hcsmatocele 

1.  Urgent  symptoms  at  onset. 

2.  Development  rapid. 

3.  Not  very  sharply  circumscribed. 

4.  Immobility  of  mass. 

5.  Signs   of   pregnancy   precede   formation   of 
mass. 

6.  Uterine  decidua. 

Ruptured  tubal  pregnancy .      Hcematocele 

1.  No  pre-existing  tumor. 

2.  History  of  pregnancy. 

3.  Tumor  not  smooth  and  tense. 

4.  Uterus  somewhat  enlarged. 

5.  Uterine  decidua. 


Ruptured  pyosalpinx 

1.  Initial  history  of  infection. 

2.  Pulse  not  so  rapid. 

3.  Rise  of  temperature  marked  from  onset. 

4.  Pain  less  intense  but  continuous. 

5.  Usually  ab.sent. 


Peltic  peritonitis  and  cellulilis 

1.  Historj'  of  infection. 

2.  Onset  less  sudden. 

3.  No  hemorrhage. 

4.  Temperature  elevated. 

5.  Usually  mass  hard:  later  may  soften. 

6.  Precedes. 

7.  Absent. 

8.  Always  leucocytosis  in  early  stages. 

Uterine  and  ovarian  tumors 

1.  Absent. 

2.  Slow. 

3.  Mass  sharply  circumscribed. 

4.  Mobility  usual. 

5.  Absent  unless  complicated  by  pregnancy. 

6.  Absent. 

Hemorrhage  into  ovarian  cyst 

1.  Pre-existing  tumor. 

2.  Absent. 

3.  Tumor  smooth  and  tense. 

4.  Not  so  much  enlarged. 

5.  Absent. 


ECTOPIC  PREGNANCY  481 

Tubal  pregnancy  I  Normal  pregnancy 

1.  Before  rupture,  Restfition-sfic  harder.  1.  Uterus  softer. 

2.  Fluctuation  and  ballottomont  absent.  2.  Fluctuation  and  ballottemont  later. 

3.  l"tcrus  sliuhtly  onlarKed.     Tumors  separate  3.  Tumor  ia  enlarged  uterus, 
from   uterus   and   crowds   it   to   oppo.site  side   of  ] 

pelvis. 

4.  I'nusual  history.  '        4.   Nothini;  unusual  in  history. 

5.  Tubal  abortion,  or  rupture  between  fourth  5.   Does  not  occur, 
and  ninth  week  usual. 

(').   Discharge    of    uterine    decidua    with    false   i       0.   Does  not  occur, 
labor  pains  occurring  usually   at  time  of  tubal  I 
abortion  or  rupture.  I 

Uterine  displacements,  pregnancy  in  one  horn  of  a  bicornate  uterus, 
perforation  of  the  stomach  or  bowel,  and  rupture  of  an  aneuri.sm  have 
been  mistaken  for  tul)al  prej^nancy,  but  none  of  these  conditions  pro- 
duce the  symptom  group  outlined  in  the  above  paragraphs  on  Diag- 
nosis. In  cases  of  ha^matocele  Huppert's  test  for  urobilin  will  give 
positive  e\u(lence  of  the  absorption  of  blood  and  the  elimination  of  it 
by  the  kidneys. 

Prognosis  of  Tubal  Pregnancy 

The  outlook  for  the  mother  always  is  doubtful  and  serious.  Spon- 
taneous recovery  is,  however,  not  uncommon.  In  former  times  pehic 
hsematocele  was  not,  in  the  majority  of  cases,  recognized  as  related  to 
tubal  pregnancy,  and  therefore  usually  was  treated  on  the  expectant 
plan.  Under  such  conditions  spontaneous  cures  were  frequent.  Our 
knowledge  of  the  true  pathology  and  the  consequent  greater  frequency 
of  operati\-e  interference  do  not  change  the  fact  that  spontaneous 
recovery  often  will  occur  just  the  same,  even  though  the  name  of  the 
condition  has  been  changed  from  hsematocele  to  tubal  pregnancy. 
However,  recovery  occurs  much  more  frequently  with  than  without 
operation.  In  two  hundred  and  seventy-eight  cases  for  which  there 
had  been  no  operation,  collected  by  Schauta,  Martin,  and  Orthmann, 
one  hundred  and  eighty-seven,  or  a  little  over  two-thirds,  died;  while 
five  hundred  and  seven,  or  80  per  cent.,  of  six  hundred  and  thirty- 
six  cases  operated  upon,  survi\-ed.^  At  the  present  time  improved 
surgical  technique  will  raise  this  percentage  of  recoveries  from  80  to 
not  less  than  95. 

In  all  cases  of  ectopic  pregnancy  at  term  the  viability  of  the  child 
as  compared  to  the  life  and  welfare  of  the  mother  is  a  very  secondary 
matter.  Few  children  are  produced  alive,  and  fewer  still  survi\-e 
many  days.  The  few  who  do  sur\dve  are  physically  and  mentally 
inferior.  Harris^  collected  a  number  of  cases  of  living  children  of 
extra-uterine  pregnancies,  and  in  1895  reported  to  Orthmann  that  of 
fifty-seven  whose  histories  he  had  been  able  to  trace  only  five  survived 
their  second  year. 

If  the  death  of  the  foetus  occur  in  the  earlier  weeks  and  the  mother 
sur\'ive,  the  subsequent  conditions  will  vary  according  as  the  embryo 
is  retained  in  its  envelopes  or  is  cast  out  free  into  the  abdominal  cavity. 
In  the  latter  case  it  may  be  absorbed  quickly ;  in  the  former,  absorption, 

1  A.  Martin.     Die  Krankheiten  der  Eileiter,  1895. 

2  American  Journal  of  the  Medical  Sciences,  August-September,  1888. 


482  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

although  slower,  is  the  usual  ultimate  result.  Gestation  that  has 
advanced  for  several  months  may  give  rise  to  a  variety  of  changes.  The 
foetus  may  undergo  a  process  of  mummification  and  remain  encaysulated 
in  the  body  of  the  mother  for  years.  Chiari  has  reported  a  case  in  which 
the  mummified  foetus  was  carried  for  fifty  years.  It  maj'  undergo 
calcareous  degeneration,  so  called,  and  become  a  lithopcedion,  and  remain 
in  that  state  for  years.  The  mummified  or  calcareous  foetus  ordinarily 
gives  little  trouble;  it,  however,  may  become  the  seat  of  suppuration, 
and  as  a  consequence  the  patient  may  succumb  to  exhaustion  from 
peritonitis  or  blood-poisoning.  On  the  other  hand,  spontaneous  open- 
ing of  the  abscess  into  the  intestine  or  vagina,  or  through  the  abdominal 
walls,  may  lead  to  recovery.  A  lithopsedion  has  been  the  mechanical 
cause  of  obstruction  in  labor. 

All  isthmic  and  ampullar  pregnancies,  if  left  to  nature,  end  with 
death  of  the  foetus.  The  tubo-uterine  variety,  i.  e.,  interstitial  preg- 
nancy, as  already  explained,  may  result  in  the  passage  of  the  embryo 
into  the  uterine  cavity  and  subsequent  normal  gestation. 

Treatment  of  Tubal  Pregnancy 

From  the  observations  already  made,  it  follows  that  the  treatment 
of  tubal  pregnancy,  as  a  general  rule,  will  be  operative.  The  safety 
of  the  patient  is  immeasurably  greater  if  the  diagnosis  is  made  and 
the  operation  performed  in  the  earlier  weeks,  before  the  time  of  tubal 
abortion  or  rupture.  Unfortunately  for  the  majority  of  cases,  the 
first  intimation  of  the  diagnosis  comes  with  one  of  these  accidents. 

The  treatment  will  vary  with  the  varying  conditions.  The  four 
possibilities  are: 

1 .  That  the  diagnosis  has  been  made  before  the  time  of  rupture  or 
abortion. 

2.  That  rupture  or  aborton  has  just  occurred. 

3.  That  the  patient  has  survived  the  immediate  effects  of  rupture 
or  abortion,  and  that  gestation  has  ceased  with  death  of  the  foetus. 

4.  That  rupture  has  occurred,  but  the  foetus  is  alive  and  gestation 
is  still  going  on. 

1.  Treatment  of  Early  Pregnancy  before  Rupture  or  Abortion. — 
The  tube  and  its  contents  should  be  removed  immediately.  Only  by 
this  means  can  the  woman  be  protected  against  the  extreme  peril 
of  continued  tubal  gestation.  The  danger  of  the  operation  is  not  greater 
than  removal  of  the  uterine  appendages  under  other  circumstances; 
the  technique  is  the  same.  In  very  many  cases  tubal  pregnancy  is 
unrecognized  until  the  abdomen  has  been  opened  upon  the  diagnosis  of 
a  supposed  hydrosalpinx  or  pyosalpinx.  This  fact,  as  Penrose  says, 
emphasizes  the  value  of  the  rule  to  operate  for  all  gross  lesions  of  the 
tube. 

2.  Treatment  Immediately  after  Rupture  or  Abortion. — The  general 
rule  is  to  operate  without  delay.  It  may  be  unwise  to  wait  for  reaction 
from  the  shock  and  hemorrhage,  for  hemorrhage  is  the  very  indication 


ECTOl'IC   rHECXASCY  483 

for  iiittTfcrence.  Iiulood,  the  iinnudiiitt.'  ()l)jt'ct  of  the  operation  is  to 
stop  the  lu'morrlia<>e. 

The  writer  has  recorded  two  cases  in  which  the  patients  were  in 
apparent  colla])se,  and  for  this  reason  it  was  not  (k'cnied  wise  to  operate 
unless  there  should  be  a  tendency  to  rally.  In  both  cases  slow  improve- 
ment and  final  recovery  followed  the  operation.  A  few  months  later 
the  i)roducts  of  conception  disappeared  by  absorption.  These  cases 
show  that  without  ()i)eration  the  })rognosis,  even  in  the  most  extreme 
conditions,  is  not  hopeless. 

Operation. — The  al)domen  is  opened  as  described  in  Chapter  \T. 
The  tube  and,  tooether  with  it,  the  broad  ligament  are  grasped  and 
pulled  into  the  wound;  two  pairs  of  strong  hcvmostatic  forceps  are  placed 
on  the  broad  ligament — one  on  the  infundibulopelvic  extension  of  it, 
near  the  pelvic  wall,  the  other  close  to  the  uterus;  this  will  control  the 
ovarian  artery  at  its  point  of  entrance  both  to  the  ligament  and  to  the 
uterus.  Ligatures  are  substituted  immediately  for  the  forceps,  the  tube 
removed,  and  htemostasis  secured  as  described  in  Chapter  XX.  If 
there  is  dead  space  between  the  folds  of  the  broad  ligament,  it  may  be 
obliterated  by  fine  buried  catgut  sutures;  or  if  too  large  to  be  sutured, 
it  may  be  sutured  into  the  abdominal  wound  and  drained  or  may  be 
drained  through  the  vagina,  as  explained  in  Chapter  XXIV.  for 
drainage  of  intraligamentous  myomata. 

If  loss  of  blood  has  been  excessive,  the  free  infusion  of  normal  salt 
solution,  tW'O  or  more  pints,  by  hypodermoclysis,  preferably  under  the 
breast,  or  the  introduction  of  it  into  the  abdomen  before  closure  of 
the  wound  as  described  in  Chapter  VII.,  is  indicated  strongly.  This 
solution,  which  may  be  used,  according  to  the  indication,  before,  during, 
and  after  the  operation,  has  turned  the  scale  for  recovery  in  many  a 
desperate  case.  If  the  hemorrhage  has  been  extreme  direct  trans- 
fusion of  blood  is  indicated. 

3.  K  Rupture  or  Abortion  Has  Occurred,  and  the  patient  has  recovered 
from  the  immediate  effects  of  it,  and  gestation  has  ceased  with  death 
of  the  foetus,  there  may  be  spontaneous  cure,  with  absorption  and  dis- 
appearance of  the  products  of  conception.  Under  these  favorable  con- 
ditions, especially  if  there  be  continuous  gradual  improvement  in  the 
symptoms,  one  may  adopt  the  plan  of  watchful  expectancy.  Frank- 
enthal  says:  "Treat  conservatively  only  those  cases  seen  some  time 
after  primary  rupture,  when  you  are  reasonably  certain  of  the  death 
of  the  foetus,  when  the  alarming  symptoms  have  subsided,  and  when, 
presumably,  absorption  is  going  on."  Intraligamentous  rupture  occur- 
ring within  the  first  three  or  four  weeks  of  gestation  is  rather  liable  to 
be  followed  by  recovery  and  absorption.  One  must,  however,  be  pre- 
pared to  operate  promptly  upon  the  least  evidence  of  secondary  rupture 
and  hemorrhage  or  upon  the  onset  of  infection.  E\'en  in  uncomplicated 
cases  of  this  third  division,  however,  it  is  permissible  to  operate,  and 
thereby  relieve  the  woman  of  the  danger  incident  to  the  presence  of  a 
dead  foetus  in  the  pelvis. 

Previous  to  the  fourth  or  fifth  month  the  entire  gestation-sac  and 


484  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

its  contents  may  be  removed  usually  without  great  danger  of  fatal 
hemorrhage.  At  least  the  hemorrhage,  if  troublesome,  may  be  con- 
trolled by  ligature  of  the  ovarian  vessels,  or  if  necessary,  of  the  ovarian 
and  uterine  vessels.  After  the  foetus  has  been  dead  for  some  time  there 
is  little  or  no  danger  of  hemorrhage  in  separating  the  placenta. 

4.  If  Gestation  has  Advanced  Beyond  the  Fourth  or  Fifth  Month,  and 
the  child  is  li\-ing,  the  removal  of  the  foetus,  together  with  the  placenta 
and  the  gestation-sac,  is  practicable  in  only  a  small  minority  of  cases, 
and  then  only  in  the  hands  of  the  expert  operator.  The  conditions 
favorable  for  this  radical  operation  are  found  in  the  rare  pedunculated 
tubal  pregnancies  already  mentioned,  in  which  gestation  may  go  to 
term  without  rupture,  and  in  other  rare  cases  in  which  the  sac  can  be 
isolated,  brought  through  the  wound,  and  a  pedicle  formed,  or  its 
attachments  separated  without  excessive  hemorrhage.  Ligature  of  the 
ovarian  and  uterine  vessels,  even  if  practicable,  does  not  control  the 
terrible  hemorrhage  which  at  this  period  and  under  ordinary  conditions 
invariably  follows  separation  of  the  placenta.  The  surgeon  must 
assume  the  great  responsibility  of  a  decision,  when  the  abdomen  is 
open,  whether  he  will  attempt  removal  of  the  gestation-sac.    The  de- 

ExTlanation  of  Plate  XXIV 

The  sac  is  spherical  in  shape  and  21  cm.  in  its  greater  diameter.  Its  wall  is  2  mm.  thick  everywhere 
except  in  the  placental  sites.  The  larger  placenta  at  its  thickest  part  measures  23  mm.,  its  greatest 
diameter  is  22  cm.  and  the  least  is  19  cm.  On  the  wall  opposite  this  placenta  is  a  second  smaller  one 
measuring  6.5  x  10  cm.  The  umbilical  cord  is  inserted  into  the  margin  of  the  larger  placenta;  from 
it  vessels  are  seen  extending  into  the  larger  portion  of  the  placenta  and  also  sending  two  large  branches 
to  the  smaller  one.  On  the  superior  margin  of  the  wall  of  the  sac  just  beneath  the  peritoneal  cover  is 
a  cyst,  spherical  in  shape,  and  1.5  cm.  in  diameter. 

The  umbilical  cord  is  33  cm.  long  and  is  similar  to  the  cord  of  a  full-term  foetus  in  other  respects. 

The  fcetu.s  lies  in  the  sac  with  its  feet  and  arms  flexed  on  the  body  as  is  typical  of  intra-uterine  life. 
It  is  43  cm.  in  length  and  is  a  male  child.  The  external  layer  of  the  skin  is  roughened  and  macerated. 
Rugse  are  present  with  irregular  regions  in  which  this  portion  of  the  skin  has  disappeared  leaving  a 
smooth  normal  skin  below. 

The  head  is  distorted,  the  forehead  bulging  on  the  left  side  as  if  there  were  some  compression  on 
the  opposite  side.  The  right  parietal  bone  is  depressed  and  the  margin  is  under  the  left  parietal.  The 
anterior  fontanelle  is  obliterated,  whereas  the  posterior  fontanelle  is  prominent  and  continuous  with 
the  ununited  lambdoid  sutures  which  can  be  traced  to  the  asterion.  The  hair  is  abundant,  light  brown 
in  color,  and  the  scalp  is  loose,  fiabb.\-,  and  wrinkled.  The  lips  have  a  greenish  discoloration.  The 
measurements  of  the  head  are  as  follows:  Mastoid  to  mastoid  (over  the  head),  22  cm.;  glabella  to 
occipital  protuberance,  22  cm.;  circumference  of  the  head,  30. 5  cm.  The  neck  is  13  cm.  in  circum- 
ference. The  thorax  is  32  cm.  in  circumference.  The  abdomen  is  23  cm.  in  circumference  just  above 
the  umbilical  cord. 

The  toe  nails  and  finger  nails  are  completely  formed.  • 

The  right  anterior  and  left  lateral  sides  of  the  thorax  are  flattened,  causing  an  irregular  bulging  of 
the  anterior  inferior  part  of  the  thorax  on  the  left  side. 

On  opening  the  abdomen  of  the  child  the  appendix  lies  free  above  the  brim  of  the  true  pelvis  curled 
upon  itself  with  a  mesentery  extending  two-thirds  of  its  length.  The  inguinal  and  femoral  rings  are 
closed.  There  is  no  visible  great  omentum  covering  the  intestine,  but  only  a  small  thin  portion  devoid 
of  fat  is  seen  between  the  transverse  colon  and  the  stomach.  The  intestines  are  collapsed,  flat,  and 
folded  on  each  other.  The  diaphragm  on  the  right  side  extends  to  the  lower  margin  of  the  third  rib 
and  on  the  left  to  the  lower  margin  of  the  fourth  rib. 

There  are  small  ecchymoses  in  the  pericardium  and  the  epicardium. 

All  the  other  viscera  are  well  formed  and  correspond  in  every  detail  to  those  of  a  normal  fidl-term 
foetus. 

Histological  Examination. — All  of  tlie  microscopical  preparations  were  cut  at  right  angles  through 
the  wall,  the  inner  surface  forming  one  edge,  the  outer  the  other  edge  of  the  sections. 

In  those  through  the  periphery  of  the  larger  placenta  the  flattened  sinuses  contain  organizing  and 
in  some  instances  calcified  thrombi,  also  hyaline  fibrin  masses  with  blood  pigment  in  them.  Some  of 
the  calcareous  masses  are  0.]5  mm.  in  diameter.  The  sections  through  the  wall  at  the  middle  of  this 
placenta  are  too  necrotic  to  stain;  near  their  inner  margin  there  are  places  reacting  to  hematoxylin 
as  though  they  contained  lime.  The  preparations  taken  from  the  edge  of  the  smaller  placenta  con- 
tain the  largest  amounts  of  lime  found;  here  the  placental  cotyledons  are  in  contact  with  scarcel.v  any 
space  between  them.  Similar  appearances  are  present  in  the  sections  through  the  centre  of  the  smaller 
placenta  where  some  difference  is  also  afforded  in  the  necrosis  of  the  outer  layers  of  the  sac  wall. 

In  the  sections  from  the  sac  wall  where  no  placenta  is  present  there  are  generally  heavy  collagenous 
fibers  with  several  collections  of  lymphocytes  and  a  few  plasma  cells,  also  rather  heavy  flattened 
blood-vessels.  In  the  sections  taken  from  the  slight  thickening  in  the  sac  verj'  definite  non-striated 
muscle  forms  the  entire  thickness  of  the  wall.  No  noteworthy  features  are  found  in  the  sections  of 
the  umbilical  cord. 

Examination  by  Dr.  E.  R.  Le  Count,  Pathologist,  .St.  Luke's  Hospital,  Chicago. 


PLATE    XXIV 


ECTOPIC  PREGNANCY  485 

liberate  attempt  to  remove  it  has  resulted  many  times  in  uncontrollaMe 
and  fatal  hemorrha<;e.  In  opening  the  sac  the  operator  accidentally 
may  incise  or  separate  the  placenta  and  find  himself  face  to  face  with 
a  most  formidal)le,  if  not  uninana^'eahle,  hem()rrha<,'e.  Compression  of 
the  aorta  and  liji;ature  of  the  uterine  and  o\arian  arteries,  if  i)romptly 
and  skilfully  executed  may  or  may  not  save  the  patient's  life. 

In  one  case  of  extra-uterine  pregnancy  after  term,  the  child  having 
been  dead  for  a  considerable  period,  I  enucleated  the  universally  at- 
tached and  adherent  gestation  sac,  controlling  small  hemorrhages 
during  the  progress  of  the  enucleation,  and  remo\ed  the  sac  intact. 
After  removal  the  unopened  sac  with  its  contents  was  fixed  in  formalin 
so  that  everything  retained  its  shape.  (Plate  XXIV.)  This  operation 
was  followed  by  complete  recovery. 

In  the  majority  of  such  cases  the  operator  must  be  content  to  incise 
the  sac,  remove  the  foetus,  stitch  the  sac  to  the  abdominal  wound, 
and  leave  the  placenta.  J.  Bland  Sutton  proposes  to  close  the  sac 
with  sutures  instead  of  stitching  it  to  the  wound.  This  is  done  in  the 
hope  that  the  placenta  will  undergo  atrophy  or  absorption.  The  danger 
of  infection  in  a  sac  thus  closed  would  be  considerable.  The  usual 
and  safer  plan,  therefore,  is  to  leave  the  placenta  and  establish  gauze 
or  tubular  drainage.  After  two  or  three  weeks,  when  the  placental 
circulation  has  ceased,  the  wound  may,  if  necessary,  be  reopened,  and 
the  placenta  taken  away,  but  the  common  practice  hitherto  has  been 
to  let  the  placenta  disintegrate  and  drain  away  as  debris. 

Some  operators  in  the  fourth  class  of  cases  prefer  to  delay  opera- 
tion until  after  term,  when  the  child  has  died  and  the  placental  cir- 
culation has  ceased.  The  products  of  conception  may  then  be  removed 
entire,  with  the  minimum  danger  of  hemorrhage.  This  plan  neces- 
sarily involves  the  dangers  incident  to  the  continued  presence  of  an 
extra-uterine  foetus,  and  should  include  as  a  positive  requirement  that 
the  patient  remain  in  a  hospital. 

The  vaginal  route  for  operation  is  permissible  only  when  hsematocele 
has  broken  down  and  given  rise  to  a  pelvic  abscess;  such  an  abscess, 
together  with  whatever  may  remain  of  the  embryo,  then  may  be 
treated  like  any  other  pelvic  abscess  by  vaginal  incision. 


CHAPTER   XXXIII 

embryology  of  the  genitalia  and  congenital 
malfor:\iations 

embryology 

An  appreciation  of  the  embryology  of  the  genitalia  is  essential  to  an 
understanding  of  malformations  and  is  important  in  the  study  of  patho- 
logical growths.  The  various  phases  of  embryological  development 
cannot  be  made  clear  by  studying  the  human  embryo  alone,  because 
in  man  the  transitions  from  one  morphological  stage  to  another  are 
less  accessible  for  study  and  in  many  details  not  apparent;  therefore 
some  of  the  following  statements  are  derived  from  the  embryology 
of  lower  vertebrates.  The  development  of  the  reproductive  system  is 
allied  so  closely  to  that  of  the  excretory  organs  that  they  must  be  con- 
sidered together.    The  general  subject  may  be  skeletonized  as  follows: 

DEVELOPMENT    OF    THE    WOLFFIAN    RIDGE 

Early  in  embryonic  life  a  portion  of  the  mesoderm  (connective-tissue 
layer)  known  as  the  intermediate  cell-mass  becomes  thickened  and 
projects  into  the  cavity  of  the  body  or  coelon  (later  peritoneal  cavity). 
This  projection  forms  a  ridge  Avhich  is  concerned  in  the  development  of 
the  genito-urinary  system,  and  is  known  as  the  JJ'olfficni  ridge. 

DEVELOPMENT    OF    THE    GENITAL    RIDGE 

On  the  surface  of  the  Wolffian  ridge  a  secondary  projection  (sexual 
gland)  is  formed  which  develops  later  into  the  testis  in  the  male  or 
the  ovary  in  the  female,  and  is  called  the  genital  ridge. 


EMBRYOLOGY    OF    THE    EXCRETORY    ORGANS 

In  connection  with  the  "Wolffian  ridge  four  elementary  structiu-es 
appear  as  follows: 

I.  Wolffian  ducts;  one  on  each  side. 
II.  The  pronephros  or  primitive  kidney  in  connection  with  the 
Wolffian  duct;  one  on  each  side. 

III.  The  mesonephros  (Wolffian  body);  one  on  each  side. 

IV.  The  metanephros;  one  on  each  side. 
(486) 


EMIUiYOl.OCY   OF   THE  CEXERATIVE  ORG  ASS  4b7 

I.  Development  of  the  Wolffian  (Pronephricj  Ducts 

The  jiroiK'pliric  diicis,  c-oniinoiily  known  as  the  WOlflian  ducts,  hejiin 
as  thit'keiiings  of  portions  of  tlic  intcrnu'diatt-  (•I'll-niasses,  one  on  each 
side.  Tiiey  undergo  complete  de\elopnient  in  man  and  liave  an  im- 
portant part  in  the  formation  of  the  urof^enital  system.  The  thickeninjjs 
project  as  solid  rods  of  cells  from  before  backward,  beginning  near  the 
region  of  the  heart  and  extending  toward  the  cloaca — that  is,  the  lower 
portion  of  the  intestine.  Tliey  lie  imbedded  in  the  sul)stance  of  tlic 
Wolffian  riilges.  Soon  after  their  formation  each  of  these  cellular  rods 
at  a  median  point  develops  a  cavity  which  extends  in  both  directions 
and  thus  converts  them  into  ducts,  the  posterior  ends  of  which  invariably 
open  into  the  cloaca.  As  already  mentioned,  the  thickenings  from  which 
the  Wolffian  ducts  arise  are  of  mesodermal  origin,  but  in  early  develop- 
ment the  posterior  ends  of  the  ducts  fuse  with  the  overlying  ectoderm. 
This  connection  is  temporary,  and  w^hile  it  lasts  gives  the  Wolffian  ducts 
the  appearance  of  having  originated  from  the  ectoderm;  some  say  it 
does  so  originate.  The  occasional  persistence  of  this  connection  may 
explain  the  presence  of  epithelial  structures  in  tumors  where  connecti\e- 
tissue  structures  naturally  would  be  expected,  and  vice  versa. 

II.  Development  of  the  Pronephros 

The  pronephros  develops  only  to  a  very  primitive  stage  in  the  human 
embryo  and  finally  is  resorbed,  although  traces  of  it  ha\-e  been  observed 
in  mature  man.  In  embryos  of  about  3  mm.  it  forms  on  each  side 
as  two  tubular  in^'aginations  of  the  epithelium  lining  the  body-ca\"ity 
and  projects  into  the  substance  of  the  Wolffian  ridge.  Each  of  these 
tubules  ends  blindly  at  one  extremity  and  at  the  other  opens  into  the 
body-cavity.  The  pronephros  has  no  physiological  significance  in  man, 
but  there  are  some  pathological  growths,  for  example,  of  the  kidney, 
which  may  be  explained  as  persistence  and  proliferation  of  some  of  the 
cells  of  the  pronephros,  but  which  otherwise  would  be  unexplainable. 

III.  Development  of  the  Mesonephros — Wolffian  Body 

The  mesonephros  is  formed  by  a  number  of  tubules  running  trans- 
versely from  the  Wolffian  duct  toward  the  coelon  on  each  side  of  the 
body  and  penetrating  the  Wolffian  ridge.  These  tubules  have  a  tem- 
porary excretory  function  in  the  human  embryo,  and  in  some  verte- 
brates they  are  the  chief  permanent  renal  organs  throughout  life. 

IV.  Development  of  the  Metanephros 

The  metanephros,  which  in  man  becomes  the  permanent  kidnei/, 
develops  from  an  outgrowth  which  begins  in  the  dorsal  aspect  of  the 
Wolffian  duct  and  in  the  tissue  surrounding  it.     In  the  embrvo  of 


488 


TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 


5  mm.  the  Wolffian  duct  presents  a  tubular  eminence  just  above  the 
point  of  its  insertion  into  the  cloaca;  this  outgrowth  becomes  the 
ureter.  The  extremity  of  the  ureter  branches  into  numerous  tubules, 
which  again  branch,  and  so  on  until  each  terminal  branch  ends  in  a 
distinct  vesicle  (primitive  vesicle).  The  vesicles  give  rise  to  several 
tubules  which  become  the  uriniferous  tubules  of  the  kidney;  they  are 

Figure  225 


GLOMEBULEOF         riSi-, 


PRONEPHROS 


GENITAL  GLAND 

(ovary  ur 
testicle) 


PRONEPHROS 


MUELLER- 
IAN    DUCT 


DUCT  OF  MESO- 
NEPHROS 


WOLFFIAN    DUCT 

(Gaertner's  duct) 


MESONEPHROS 

(Wolffian  body, 
temporary  kid- 
ueyj 


GLOMERULE 
OF  MESO- 
NEPHROS 


ARTERY   OF 
MESONEPHROS 


ETANEPH- 

Ros  (perma- 
nent kidney) 


ALLANTOIS 


Excrementary  organs  of  the  embryo,  showing  genital  gland,  pronephros,  mesonephros,  metanephros, 

aorta,  and  allantois. 


coiled  upon  themselves  in  the  form  of  the  letter  S.  The  lower  por- 
tion of  each  tubule  is  surrounded  by  proliferating  cells  into  which  the 
renal  artery  branches  so  as  to  form  the  glomeruli  of  the  kidney,  and 
the  walls  of  this  lower  portion  of  each  tubule  become  converted  into 
a  capsule  of  Bowman.  Additional  tubules  form  from  the  primitive 
vesicles,  giving  rise  to  a  large  number  of  glomeruli.  The  vesicles 
themselves  elongate  finally  and  form  the  collecting  tubules,   which 


EMBRYOLOGY  OF   THE  CENERATIVE  ORGANS 


489 


Fl<iLKE    --'  ' 


WOLFFIAN 
DUCT 


MESONEPHROS 

'Wollliaii  body, 
tcmijorary  kid- 
!iiey> 


GUBERNAC 
—  ULUM    OF 
HUNTER 


DEVELOPING 
UTERUS 


WOLFFIAN 
DUCT 


Reproductive  organs  of  the  embryo :  lower  part  of  Mueller's  ducts  coalescing  to  form  the 
uterus  and  vagina.  Differentiation  of  sex  is  just  beginuinR  by  the  development  of  the  genital 
glaud  into  an  ovary. 


FiGUHE  227 


GENITAL  GLAN  0 


WOLFFIAN 
DUCT 


MESONEPHROS 

:  I  Wolffian  body, 
temporary  kid- 

:neyj 


Same  as  Figure  226.   Uterus  further  developed,  but  Mueller's  ducts  still  separable  ;  ovaries  ana 
Fallopian  tubes  more  developed.    WolfiBan  bodies  and  Wolffian  ducts  undergoing  atrophy. 

30 


490  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

Figure  228 


OVARY  (gen- 
ital gland) 

FALLOPIAN 

TUBE  (Muel- 
lerian  uuct) 


GAERTNER'S 

DUCT  (remains, 

of  Wolffian 

duct) 


jPAROVARIUM    OR 
[EPOOPHORON 

I  (remains  of 
I'mesonephros  or 
!  Wolffian  bodyj 


PAROOPHORON 

(yellow  body 
of  Waldeyef; 


guberna: 

ULUM    OF 
HUNTER 


Same  as  Figure  227.  Each  rudimentary  W^olfEan  duct  and  body  now  appear  as  the  parovarium 
above,  and  the  paroophoron  below.  Uterus,  Fallopian  tubes,  and  ovaries  almost  fully  developed. 
Lower  part  of  Mueller's  ducts  persist  as  developed  uterus. 

open  separately  into  the  pelvis  of  the  kidney.  The  number  of  the 
primitive  vesicles  which  form  in  the  human  kidney  is  about  eighteen, 
and  each  one  corresponds  to  a  fully  developed  lobe. 


EMBRYOLOGY  OF  THE  GENERATIVE  ORGANS 

In  close  developmental  relations  wdth  the  organs  already  described, 
w^hich  are  mainly  excretory,  may  now'  be  introduced  the  embryonic 
structures  which  have  more  especially  a  generative  significance;  they 
are: 

I.  The  ducts  of  Mueller. 
II.  The  genital  ridge. 
III.  The  urogenital  sinus. 


I.  Development  of  the  Ducts  of  Mueller 

When  the  mesonephros  (Wolffian  body)  has  reached  the  height  of 
its  development,  invaginations  form  in  the  peritoneum  covering  the 
Wolffian  ridge,  and  these  invaginations  are  the  beginnings  of  the 
Muellerian  ducts,  which  are  imbedded  in  the  first  part  of  their  course 


DEVELOPMENT  OF  EMBRYONIC  STRUCTURES  INTO  ORGANS     491 

in  the  substance  of  the  ridge  itself.  The  forming  ducts  become  dis- 
connected from  the  peritoneum  except  at  one  small  point,  and  con- 
tiiuie  to  grow  as  two  solid  rods  of  cells  by  proliferation  of  their  ends. 
Presently  they  acquire  a  lumen  which  develops  throughout  their 
length. 

The  ducts  of  ^Mueller  are  situated  to  the  outer  side  of  the  Wolffian 
ducts,  except  in  the  lower  portion  of  their  course,  where  they  are 
situated  between  them.  In  human  embryos  of  22  mm.  they  have 
attained  their  full  length,  and  finally  they  fuse  together  at  the  lower 
end  to  form  the  uterus  and  vagina,  the  upper  portion,  however,  re- 
maining separate  to  form  the  Fallopian  tubes. 

II.  Development  of  the  Genital  Ridge 

As  already  stated,  one  portion  of  the  intermediate  cell-mass  on 
each  side  of  the  body  cavity  constitutes  the  Wolffian  ridge,  and  the 
other  portion,  known  as  the  genital  ridge,  forms  the  sexual  gland — 
that  is,  the  ovary  in  the  female  and  the  testis  in  the  male.  The  epithe- 
lial cells  of  that  region  assume  a  high  columnar  form  and  grow  several 
layers  thick,  the  connective  tissue  beneath  proliferating  at  the  same 
time  so  as  to  form  a  distinct  elevation  or  ridge.  This  thickened  epithe- 
lial layer  (germinal  epithelium  of  the  ovary)  is  concerned  in  the  forma- 
tion of  the  egg  cells.  Some  of  the  cells  of  the  germinal  epithelium  are 
seen  to  be  larger  and  more  spherical  than  others;  these  are  the  primordial 
ova  out  of  which  develop  the  sexual  glands. 

III.  Development  of  the  Urogenital  Sinus 

The  terminal  portion  of  the  intestinal  canal  is  called  the  cloaca;  it 
persists  as  a  common  opening  for  the  intestinal  and  the  urogenital 
system  until  after  the  fifth  week  of  foetal  life;  the  allantoic  duct  (allan- 
tois)  opens  into  it.  The  upper  portion  of  the  allantois  enlarges  and 
becomes  the  bladder,  while  the  lower  portion  remains  narrow.  Into 
the  lower,  narrow  portion  open  the  ducts  of  Mueller,  one  on  each  side. 
The  junction  of  the  Muellerian  ducts  with  the  narrow  portion  of  the 
allantois  divides  the  latter  into  two  parts;  the  part  above  the  junction 
represents  the  urethra,  while  the  part  below  is  the  urogenital  sinus.  The 
urogenital  sinus  forms  the  vestibule  in  the  female,  while  in  the  male 
it  is  included  in  the  formation  of  the  urethra. 

DEVELOPMENT  OF  EMBRYONIC  STRUCTURES  INTO  ORGANS 

The  pronephros  (primitive  kidney)  has  no  physiological  significance 
in  man.  The  development  of  the  metanephros  into  the  permanent 
kidney  in  man  has  been  described.  It  remains  to  consider  what 
becomes  of  the  Wolfiian  ducts.  Wolffian  body,  the  ducts  of  ]\Iueller, 
the  genital  ridge,  and  the  urogenital  tissues;  the  following  explanations 
and  tabular  statements  accordingly  are  set  forth. 


492 


TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


\Yhat  Becomes  of  the  Wolffian  Body  axd  Ducts 

In  the  eighth  week  of  the  female  embryo  the  ^Yolffian  body  begins 
to  undergo  atrophic  changes  and  is  resorbed  slowly,  except  a  small 
anterior  portion,  which  persists  and  enters  into  the  formation  of  the 
sexual  organs,  the  resorption  being  much  more  extensive  in  the  female 
than  in  the  male. 

The  Wolffian  duct  and  the  remnant  of  the  Wolffian  body  give  rise 
to  the  following  homologous  structures  in  the  two  sexes: 


In  the  embryo 

1.  Wolffian  duct. 

2.  Wolffian     body,     anterior 
(sexualj  portion. 

3.  Wolffian  body,  inferior  por- 
tion. 


In  the  adult  female 

1.  Duct  of  Gaertner. 

2.  Parovarium  (epoophoron). 

■3.   Paroophoron. 


In  the  adult  male 

1.  Vas  deferens. 

2.  Epididymis. 

•3.   Paradidymis   (organ    of 
GiraldSs) . 


At  the  lower  middle  part  of  the  Wolffian  duct  is  an  offshot,  the 
gubernaculum  of  Hunter,  which  passes  through  the  canal  of  Xuck, 
and  which  by  contracting  draws  the  parovarium,  and  with  it  the 
ovary,  down  to  its  normal  location  in  the  posterior  fold  of  the  broad 
ligament.  The  contraction  of  this  cord  therefore  is  concerned  with  the 
descent  of  the  ovary.  In  rare  cases  this  contraction  is  so  excessive 
as  to  draw  the  ovary  through  the  canal  of  Xuck,  and  thereby  to 
produce  a  serious  displacement  of  the  ovary. 

The  Parovarium  fEpobphoron,  Organ  of  RosenmueUer) 

The  paro^'arium  is  a  remnant  of  the  anterior  portion  of  the  Wolffian 
body,  and  is  situated  between  the  ovary  and  the  Fallopian  tube  in  the 
folds  of  the  broad  ligament;  it  consists  of  a  number  of  tubules  which 
open  into  Gaertner's  duct,  this  duct,  as  shown  in  the  above  table, 
being  a  remnant  of  the  Wolffian  duct. 

Paroophoron  (Yellow  Body  of  Waldeyer) 

The  paroophoron  is  a  remnant  of  the  inferior  portion  of  the  Wolffian 
body,  is  situated  between  the  folds  of  the  broad  ligament  near  the 
uterus,  and  is  composed  of  a  number  of  small  blind  tubules  connecting 
with  one  another. 


What  Becomes  of  the  Ducts  of  Mueller 


The  ]Muellerian  ducts  in  the  male  become  rudimentary;  in  the 
female  they  form  the  Fallopian  tubes,  uterus,  and  vagina. 

The  homologous  structures  in  the  two  sexes  developed  from  the 
ducts  of  ^Mueller  are  as  follows: 


DIFFERENTIATION  OF  SEX 


493 


Duct  of  Mueller.   In  the  embryo     Duct  of  Mueller.     In  the  adult      Duct  of  Mueller.      In   the  adult 


1.   Upper  extremity. 


2.   Middle  ununited  portion. 


3.  Lower  uixited  portion. 


female 

1.  Fimbriated  extremity  of 
Fallopian  tube  (the  hydatid  of 
Morcasni  as  usually  desiRnated 
in  the  female  i.s  a  vesicle  attach- 
ed to  one  frinibria). 

2.  Fallopian  tube. 


3.   Uterus  and  \  agina. 


nude 
1.   Hydatid  of  MorEagni. 


2.  Comua  uteri  masculini 
(usually  ab.sent,  sometimes 
rudimentarj-). 

3.  Uterus  masculinus  (nidi- 
rnentao'  and  in  close  connec- 
tion with  the  prostate  gland). 


What  Becomes  of  the  Genital  Ridge? 

The  structures  originating  in  the  genital  ridge  in  both  sexes  are 
developed  as  follows: 


Genital  ridge  in  the  embryo 
Germinal    epithelium    of    the 

genital  ridge. 

Mesoblastic    portion    of    the 

genital  ridge. 


Genital  ridge  in  Ike  adult  female 
Graafian  follicles. 

Stroma  of  the  ovar\-. 


Genital  ridge  in  the  adult  male 
Epithelium  of  the  seminifer- 
ous tubules. 

Connective     tissue     of     the 
testicle. 


What  Becomes  of  the  Ueogexital  Sinus  .and  Xeighborixg 
Structures  ? 

In  this  connection  the  student  is  referred  to  Figures  236-240  and 
the  accompaming  text. 


Urogenital  sinus  in  the  embryo 

1.  L^pper  portion  of  the  uro- 
genital sinus. 

2.  Lower  portion  of  the  uro- 
genital sinus. 

3.  Epithelial  involutions  of 
sides  of  urogenital  sinus. 

4.  Genital  eminences  and 
folds  (neighboring  structures 
on  both  sides  of  urogenital 
sinus). 

.5.  Integument  on  either  side 
of  orifice  of  urogenital  sinus. 


Urogenital  sinus  in  the  adult 
female 

1.  Urethra. 

2.  Vestibule. 


3.  Glands  of  Bartholini. 

4.  Clitoris  and  njinphae. 

5.  Labia  majora. 


Urogenital  sinus  in  the  adult 
male 

1.  Upper  prostatic  portion 
of  urethra. 

2.  Lower  prostatic  portion 
of  urethra  and  membranous 
portion  of  urethra. 

3.  Cowper's  glands. 

4.  Penis. 


5.  Scrotum. 


DIFFERENTIATION  OF  SEX 


From  the  foregoing  paragraphs  and  tables  it  will  be  seen  that  if 
the  genital  ridge  develops  into  an  ovary,  the  result  will  be  a  female; 
if  into  a  testicle,  the  result  vn[\  be  a  male. 

On  one  hand,  along  with  the  differentiation  of  the  genital  ridge 
into  an  ovary,  the  Muellerian  ducts  develop  into  Fallopian  tubes, 
uterus,  and  vagina,  while  the  Wolffian  ducts  and  body  atrophy,  leav- 
ing behind  only  rudimentary  structures.  On  the  other  hand,  along 
with  the  differentiation  of  the  genital  ridge  into  a  testicle,  the  reverse 
happens — that  is,  the  Muellerian  ducts  atrophy  and  the  Wolffian  ducts 
and  Wolffian  body  become  important  male  organs — epidid\Tnis  and 
vas  deferens. 

The  development  of  the  external  genitalia  follows  the  same  lines 
in  both  sexes,  except  development  in  the  male  is  more  extensive  than 


494  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

in  the  female,  being  arrested  in  the  female  with  the  formation  of  the 
clitoris,  nymphse,  and  labia  majora,  but  going  on  in  the  male  to  the 
development  of  the  penis  and  scrotum.  In  one  sense  the  clitoris 
embryologically  may  be  regarded  as  an  undeveloped  penis  and  the 
labia  as  an  undeveloped  scrotum. 


CONGENITAL  MALFORMATIONS 

Malformations  may  be  due  to  arrested  development  or  to  excessive 
development.  In  the  first  class  of  anomalies  we  have  the  malforma- 
tions due  to  the  persistence  of  embryonal  conditions;  the  second  class 
includes  the  h;v^ertrophies  and  multiplications  of  otherwise  normal 
organs  and  tissues. 

This  subject  should  be  studied  in  connection  with  the  first  part  of 
this  chapter  on  Embryology. 


MALFORMATIONS  OF  THE  OVARIES 

Malformations  of  the  ovaries  consist  mainly  in  lack  of  development 
or  in  excessive  development.    The  principal  anomalies  are: 

Accessory  or  constricted  ovaries. 

Supernumerary  ovaries. 

Absence  of  the  ovaries. 

Rudimentary  ovaries. 

Congenital  hj'pertrophy  of  the  ovaries. 

Congenital  displacement  of  the  ovaries. 
Accessory  Ovaries  are  found  in  a  small  percentage  of  autopsies. 
They  are  always  of  small  size,  and  generally  are  connected  with 
normal  ovaries  by  a  pedunculated  or  sessile  attachment.  Two  or 
three  may  be  found  in  one  case.  They  are  usually  parts  of  the  original 
ovary  separated  during  late  foetal  life  by  the  constriction  of  peritonitic 
bands.  The  ovary  thus  may  be  divided  into  equal  halves  or  may  be 
divided  only  partially.  The  presence  of  accessory  ovaries  may  account 
for  pregnancy  after  both  ovaries  are  supposed  to  have  been  removed. 
Supernumerary  Ovaries.  —  Only  one  authentic  case  has  been 
reported.^  This  was  a  third  ovary  situated  in  front  of  the  uterus 
in  direct  relation  with  the  bladder,  and  connected  to  the  uterus  by  a 
strong  ovarian  ligament.  This  ovary  was  twice  the  normal  size.  The 
two  other  ovaries  were  normal  and  of  equal  size.  There  was  no  trace 
of  peritonitis  in  the  neighborhood. 

Absence  of  the  Ovaries  is  a  rare  condition.  It  usually  is  associated 
with  imperfect  development  or  absence  of  one  or  more  of  the  other 
sexual  organs.  An  absolute  diagnosis  can  be  made  only  by  autopsy, 
for  the  ovary  may  be  present  in  an  abnormal  location  or  in  a  partially 
developed  state,  and  therefore  may  be  overlooked.     Absence  of  one 

1  Winckel  in  AUbutt  and  Playfair,  System  of  Gynecology. 


.UALFORMATIOXS  OF   THE  OVARIES  495 

ovary  is  apt  to  he  associated  with  absence  of  the  corresponding  half 
of  the  uterus  and  Fallopian  tube.  The  writer,  however,  in  one  case  has 
t)perate(l  for  the  removal  of  the  suppurating  right  tube  and  ovary, 
and  found  a  })erfectly  develoj)ed  uterus  and,  so  far  as  could  be  dis- 
covered, entire  absence  of  the  left  tube  and  ovary.  There  was  only 
a  slight  protuberance  at  the  left  uterine  cornu  to  mark  the  point  where 
the  tube  should  have  joined  the  uterus.  Figure  220,  .1.  August  Martin 
reports  a  similar  case. 

Rudimentary  Ovaries  are  rather  uncommon.  They  are  of  small 
size,  and  the  (Graafian  follicles  are  absent  or  rudimentary.  The  uterus 
may  be  normal  or  rudimentary. 

Congenital  Hypertropliy  of  the  Ovaries. — Excessive  growth  of  the 
ovary  has  been  recorded,  i)ut  cannot  l)e  classed  strictly  as  a  malforma- 
tion. It  has  been  attributed  to  hypera^mic  or  inflammatory  conditions 
during  foetal  life. 

Congenital  Displacement  of  the  Ovary. — The  following  is  quoted 
from  Ballantyne  in  Allbutt  and  Playfair's  Systein  of  Gynecology: 
— "  Xon-descent  of  an  ovary  is  a  rare  but  not  unknown  anomaly. 
Bland  Sutton  has  reported  a  case  in  which  the  right  ovary  was  ad- 
herent to  the  lower  border  of  the  kidney  on  the  same  side,  and  I  have 
seen  a  case  in  the  newborn  infant  in  which  it  was  attached  by  peri- 
tonitic  bands  to  the  caecum.  ■  It  has  been  stated  that  it  may  be  found 
free  in  the  peritoneal  cavity.  Instead  of  non-descent,  there  may  be 
dislocation  of  the  ovaries  downward  into  the  inguinal  canal.  According 
to  Puech,  congenital  inguinal  hernia  of  the  ovary  is  much  more  common 
than  acquired,  and  Zinnis  recently  has  reported  an  instance  of  it; 
Bland  Sutton  states  that  he  knows  of  no  case  in  which  the  ovarian 
nature  of  the  herniated  body  has  been  proved  by  microscopical  exami- 
nation conducted  by  a  competent  observer.  Herniation  of  the  ovary, 
which  may  be  unilateral  or  bilateral,  is  associated  usually  with  dis- 
placement of  the  Fallopian  tube,  and  sometimes  with  malformation  of 
the  uterus  and  malposition  of  the  kidney.  It  may  be  due  to  defective 
development  of  the  round  ligament  and  a  patent  condition  of  the 
canal  of  Xuck." 


Clinical  Significance  of  Ovarian  Malformation 

The  absence  of  one  ovary,  if  the  other  is  developed  perfectly,  does 
not  render  the  woman  sterile.  On  the  contrary,  her  reproductive 
functions  may  be  in  no  practical  respect  impaired.  If  both  ovaries 
are  rudimentary  or  absent,  sterility  is  inevitable.  There  is  usually 
wanting  in  such  cases  the  normal  development  at  puberty;  there  may 
also  be  an  associated  faulty  general  nutrition,  a  weak  nervous  organi- 
zation, chlorosis,  and  not  uncommonly  a  growth  of  hair  on  the  face, 
especially  the  upper  lip.  The  individual  may  retain  the  general  physi- 
cal characteristics  of  infancy  and  childhood,  or  there  may  be  an 
apparently  full  development  of  the  extrapelvic  organs. 


496  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

Diagnosis  of  Ovarian  Malformation 

The  diagnosis  of  ovarian  malformations  is  made  by  the  above  signs 
and  symptoms  and  by  the  recognition  on  conjoined  examination  of 
undeveloped,  absent,  accessory,  or  otherwise  anomalous  ovaries.  Early 
and  accurate  diagnosis  is  important,  for  only  by  this  means  will  the 
woman  be  saved  from  a  possible  long-continued  and  useless  treat- 
ment for  sterility.  It  is  often  impossible  to  say  that  an  apparently 
rudimentary  ovary  is  congenital,  for  it  may  have  been  subject  to 
atrophic  changes  consequent  upon  the  acute  infectious  diseases  of 
childhood. 


MALFORMATIONS  OF  THE  FALLOPIAN  TUBES 

Malformations  of  the  tubes  are  analogous  to  those  of  the  ovary, 
and  are  therefore  as  follows : 
Supernumerary  tubes. 
Accessory  tubes  and  ostia. 
Increased  length  and  excessive  convolution. 
Rudimentary  development. 
Absence  of  the  tubes. 

Supernumerary  Tubes  may  be  associated  with  supernumerary  ovaries. 
Only  a  few  cases  have  been  recorded. 

Accessory  Tubes  and  Ostia  are  not  uncommon.  As  many  as  six 
accessory  ostia  have  been  observed  in  one  tube.  The  anomaly  has 
no  definitely  recognized  significance. 

Increased  Length  and  Excessive  Convolution  of  the  tubes  may 
exist,  and  have  been  said  to  favor  tubal  pregnancy. 

Rudimentary  Development. — The  rudimentary  tube  is  usually  im- 
perforate, being  a  mere  fibrous  cord,  with  perhaps  the  semblance  of 
an  open  ampulla  and  fimbriae.  The  corresponding  ovary  may  or  may 
not  be  also  rudimentary  or  absent.  The  accident  is  due  to  failure  of 
development  of  Mueller's  duct. 

Absence  of  the  Tube  pertains  more  frequently  to  one  than  to  both 
sides.  When  both  tubes  are  absent  the  uterus  and  ovaries  also  are 
usually  wanting.  Cases  have  been  recorded  in  which  the  tube  and 
kidney  on  the  same  side  were  absent.  Absence  of  one  tube  is  asso- 
ciated usually  with  lack  of  development  of  the  corresponding  side  of 
the  uterus — that  is,  with  litems  unicornis. 

The  Clinical  Significance  of  malformations  of  the  tubes  is  much  the 
same  as  that  already  outlined  for  malformations  of  the  ovaries. 


MALFORMATIONS  OF  THE  UTERUS 

The  developmental  defects  of  the  uterus  form  a  large  proportion 
of  the  genital  malformations.     They  may  be  ranged,  for  the  most 


MALFORMATIOXS  OF   THE   UTERUS  497 

part,  under  two  jjeneral  heads:  (1)  Those  due  to  imperfect  develop- 
ment of  Mueller's  ducts.  (2)  Those  due  to  imjxTfcct  l)lendin<;  of 
Mueller's  ducts. 

Infantile  Uterus.  -If  the  Mucllcrian  ducts  unite  hut  do  not  con- 
tinue to  develop,  the  result  will  be  an  undeveloped,  infantile,  or  foetal 
uterus.  If  the  arrest  of  development  occurs  very  early  in  foetal  life, 
the  uterus  will  he  extremely  rudimentary.  It  may  consist  of  an  infantile 
cer\"ix,  and  in  place  of  the  corpus  only  a  fil)rous  cord  extendinic  from 
the  site  of  one  Fallopian  opening  to  the  other.  If  arrest  of  develoj)- 
ment  does  not  occur  until  after  birth,  the  uterus  will  be  smaller  than 
normal,  but  in  other  respects  not  strikingly  different  from  the  fully 
developed  organ. 

The  anomalies  due  to  defective  blending  of  Mueller's  ducts  are 
numerous  and  frequent.  Nearly  every  degree  of  imperfect  fusion  has 
been  observed.    The  following  anomalies  are  due  to  this  cause. 

Double  Uterus. — The  most  extreme  anomaly  due  to  defective  blend- 
ing is  the  double  uterus  (uterus  didelphys),  in  which  there  are  two 
complete  organs  lying  side  by  side,  each  !Muellerian  duct  ha\"ing  formed 
a  perfect  uterus  with  cervix  and  fundus,  but  with  only  one  cornu,  one 
Fallopian  tube,  and  one  round  ligament.  Both  of  these  uteri  may 
be  functionally  competent.  Pregnancy  and  parturition  therefore  may 
proceed  normally.  On  the  other  hand,  one  uterus  may  be  rudimentary 
or  imperforate.  If  the  imperforate  organ  is  functionally  active,  it  may 
become  distended  with  menstrual  blood  and  form  hsematometra.  This 
will  require  surgical  interference. 

Accessory  Uterus. — A  xqvx  curious  and  rare  malformation  is  the 
uterus  accessorius.  In  this  condition,  besides  the  normal  uterus, 
there  exists  another  uterus  anteriorly,  between  it  and  the  bladder. 
In  one  case  a  third  uterine  lobe  was  found  attached  to  the  single  cervix 
of  a  bifid  uterus.  It  is  difficult  to  account  for  these  anomalies.  The 
assumption  has  been  made  that  the  accessory  organ  was  developed 
from  a  di\'erticulum  of  a  Muellerian  duct. 

Bicornate  Uterus. — Next  in  importance  to  the  double  uterus  is 
the  much  more  frequent  bicornate  uterus,  in  which  fusion  of  ^Mueller's 
ducts  has  occurred  lower  down  than  normal,  with  the  result  of  pro- 
ducing a  Y-shaped  organ.  This  deformity  occurs  in  all  degrees.  In 
one  extreme,  the  septum  extends  the  whole  length  of  the  cervix  and 
gives  rise  to  a  double  os  externum,  Figm-e  231;  in  the  other  extreme 
the  two  cornua  may  be  separated  only  by  a  notch  at  the  fundus  (uterus 
cordiformis) . 

A  unique  case  occurring  in  the  author's  practice  in  which  the  uterus 
was  bicornate  is  perhaps  worthy  of  note.  The  patient  was  thirty-five 
years  of  age,  married  fifteen  years,  the  mother  of  two  children,  and  a 
sufferer  from  endometritis,  extreme  dysmenorrhoea,  and  neurasthenia. 
The  faulty  general  nutrition  was  thought  to  depend  largely-  upon  the 
dysmenorrhoea.  The  patient  gave  a  history  of  having  been  treated 
for  a  long  time  and  in  many  ways,  the  treatment  having  included 
dilatation  and  curettage  of  the  uterus.    Examination  showed  that  the 


498  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS 


FiGrEE  229 


E 


A.  Absence  of  the  left  ovary  and  Fallopian  tube,  with  full  development  of  the  other  genital 
organs.  Author's  case.  The  right  tube  and  ovary  were  removed  for  pvosalplnx  and  ovarian 
abscess :  recovery. 

B.  Fallopian  tube  with  accessory  ostium  on  right  side.  Fallopian  tube  with  accessorv  tube 
on  left  side. 

C.  Double  uterus— i.  e.,  uterus  didelnhvs.  From  each  uterus  there  is  one  tube  and  one 
ovary.    The  vagina  is  also  double. 

D.  Uterus  septus  duplex.    Completely  divided  uterus  and  incompletely  divided  vagina. 

E.  Pabbon-sbaped  rudiment  of  uterus;  rudimentary  Fallopian  tubes,  ovaries,  and  round 
ligaments  ;  vagina  well  developed. 

F.  Uterus  with  one  horn  (uterus  unicornis).  Left  horn,  ovary,  and  Fallopian  tube  very 
rudimentarv. 


MALFORMATIONS  OF   THE   UTERUS 


4f)9 


uterus  was  bicornate,  as  represented  in  Fi<i:ure  231,  a  fact  which  hitherto 
had  not  been  recognized.  With  considerable  hesitation  and  after 
consultation,  it  was  decided  to  remove  the  two  horns  of  the  l)icornate 
uterus,  and  the  ojjcration  was  ])crformed  as  shown  in  Figures  2'M  to 
'2'A-i.  The  result  was  complete  restoration  to  health.  Six  months  after 
the  operation  the  general  nutrition  had  become  normal,  and  there  was 
an  increase  in  weight  of  about  twenty  pounds.  Although  supravaginal 
hysterectomy  would  not  ordinarily  be  acKocated  as  a  projxT  treatment 
for  dysmenorrhoea,  yet  the  peculiarities  of  this  rare  case  were  such  that 


Figure  230 


Double  uterus,  vagina,  and  vulva. 

perhaps  the  operation  was  justifiable.  At  any  rate  it  appears  to  have 
been  justified  by  the  result.  The  author  is  unable  to  find  any  record 
of  a  similar  operation,  or  for  that  matter  of  the  removal  of  any  part 
of  a  bicornate  uterus,  on  a  similar  indication. 

Uterus  Septus. — In  this  anomaly  there  is  complete  division  of  the 
uterus  into  two  cavities  by  an  anteroposterior  ^•ertical  partition  or 
septum.  The  septum  may  be  complete  or  incomplete,  may  form  only 
a  ridge  on  the  interior  of  the  uterus,  may  extend  through  the  cervix, 
or  it  may  be  confined  to  the  cervix  or  to  the  corpus.    There  may  be, 


500  TUMORS,   TUBAL   PREGNANCY,   MALFORMATIONS 

Figure  231 


Figure  232 


Figure  233 


Figure  234 


Figure  231. -Uterus  bieornis  unicollis.  The  horns  of  the  bicornate  uterus  are  continuous 
with  one  necli.  The  dotted  line  shows  the  line  of  incision  for  the  removal  of  the  two  horns 
of  the  uterus. 

Figure  232.— Same  as  Figure  230.  The  two  horns  of  the  uterus  have  been  removed  :  section 
of  Fallopian  tubes ;  section  of  uterine  canal  made  through  the  two  horns  of  the  bicornate 
uterus     Black  and  white  lines  here  indicate  the  Y-shape  of  the  bicornate  uterine  canal. 

Figure  233.— Same  as  Figure  '231.  First  stitch  in  the  union  of  the  wound  made  by  removal 
of  the  two  horiis  of  the  bicornate  uterus.  .,    ^ 

Figure  234.— Same  as  Figure  232.  Uterine  part  of  wound  brought  together  from  side  to 
side,  and  united  by  continuous  suture.  End-to-end  approximation  of  the  broad  ligaments  and 
Fallopian  tubes  by  same  suture. 


MALFORMATIOXS   OF   THE    VAdJA'A  501 

in  fact,  every  possible  variety  in  the  situation  or  coniijlcteness  of  the 
septum.  The  ty|)ieal,  if  not  eommonest,  form  has  two  hiteral  cavities 
for  both  (■ori)us  and  (-(Txix  uteri.  The  bicornate  and  septate  uteri 
have  a  simihir  cHnical  siti;nificance.  In  either  tliere  is  hable  to  be  an 
imperforate  coiuHtion  of  one  side  of  the  septum  or  the  other,  with 
resultinij  ha>matometra.  Menstruation  is  ajjt  to  be  frequent  and  other- 
wise abnormal,  and  j)arturition  to  be  embarrassed.  Uterus  suhseptus 
signifies  an  imperfect  septum  and  consequent  partial  division.  In  a 
subseptate  uterus  malpresentations  are  prone  to  occur  and  the  insertion 
of  the  placenta  to  be  abnormal. 

There  is  in  the  above  varieties  of  malformations  of  the  uterus  a 
complete  gradation  between  double  uterus  on  the  one  hand,  and 
uterus  septus  on  the  other. 

Uterus  Unicornis. — When  there  is  failure  of  fusion  and  more  or 
less  atrophy  of  the  duct  on  one  side,  so  that  only  one  horn  of  the 
uterus  is  well  developed,  or  only  one  exists,  we  have  the  single-horned 
uterus,  or  uterus  unicornis.  Figure  229,  F.  The  kidney,  ureter,  liga- 
ments, tube,  and  ovary  on  the  side  of  the  lacking  or  imperfect  cornu 
are  also,  as  a  rule,  rudimentary  or  absent.  The  rudimentary  horn  may 
be  hollow  or  solid ;  if  the  former,  its  cavity  may  or  may  not  connect  wdth 
that  of  the  lower  part  of  the  uterus.  If  menstruation  takes  place  in 
the  closed  horn,  there  will  be  hsematometra,  and  the  normal  progress  of 
menstruation  on  the  other  side  will  lead  to  confusion  in  the  diagnosis. 
Bilateral  haematometra,  both  horns  being  imperforate,  would  give  rise 
to  less  difficulty  in  the  diagnosis. 

Among  the  less  important  anomalies  of  the  uterus  are  the  following : 

Defect  or  absence  of  the  vaginal  portion  of  the  cervix. 

Septate  os  externum,  with  no  trace  of  septum  above. 

Normal  development  on  one  side  and  defective  development  on  the 
other;  this  would  be  an  approach  to  a  unicornate  uterus. 

Flat  or  arched  fundus. 

Congenital  prolapse,  retroversion,  retroflexion,  or  anteflexion. 

Congenital  communications  between  the  endometrium  and  intestine 
or  bladder. 

In  a  remarkable  case  one  side  of  a  double  uterus  is  said  to  have 
developed  on  the  exterior  of  the  body. 

Premature  Development  of  the  Uterus. — This  usually  is  associated 
with  similar  precocity  in  the  other  genital  organs.  Young  girls  thus 
may  menstruate  at  a  very  early  age  and  show  the  sexual  development 
of  mature  years. 


MALFORMATIONS  OF  THE  VAGINA 

The  vagina,  in  common  with  the  uterus,  as  shown  above,  is  formed 
by  the  coalescence  of  Mueller's  ducts,  and  therefore  shares  largely  in 
the  malformations  of  that  organ.  Thus  the  double  uterus  and  the 
uterus  septus  may  be  associated  with  double  vagina. 


502  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS 

The  congenital  anomalies  of  the  vagina  are: 
Double  vagina  (vagina  septa). 
Absence  of  vagina. 
Atresia  of  vagina. 

Vagina  Septa. — A  completely  double  vagina  having  two  canals,  each 
opening  into  an  external  vulva  of  its  own,  is  very  rare,  only  one 
case,  that  of  Katharin  Kaufmann,  having  been  reported.  In  this  case^ 
the  pelvis  was  divided  by  a  peritoneal  fold  into  two  lateral  cavities; 
each  half  contained  a  bladder,  a  unicornate  uterus,  an  ovary,  a 
Fallopian  tube,  and  a  rectum.  The  spinal  cord  was  bifurcated  at 
the  level  of  the  third  lumbar  vertebra. 

The  ordinary  and  much  more  common  double  or  septate  vagina  is 
divided  into  two  passages  by  a  septum  above  the  vulva.  The  hymen 
may  have  one  or  two  openings,  and  the  septum,  as  in  the  uterus,  may 
be  complete  or  partial. 

Double  uterus  and  double  vagina  often  coexist.  In  some  cases  the 
vagina  is  double  and  the  uterus  single,  with  the  os  externum  then  open- 
ing into  one  side  of  the  double  vagina.  The  other  side  ends  in  a  cul- 
de-sac.  If,  under  these  conditions,  the  blind  passage  alone  be  used 
for  coition,  sterility  will  result.  In  other  cases  both  sides  may  be  in 
communication  with  the  uterus.  The  septum  may  be  so  imperfect 
as  to  constitute  only  a  ridge  along  the  posterior  and  anterior  walls  of 
the  vagina. 

The  septum  seldom  divides  the  passage  into  two  equal  parts.  Coitus 
usually  is  confined  to  one  side.  In  case  of  uterus  unicornis  the  vagina 
may  be  very  small — in  fact,  of  only  half  size.  This  is  because  one  of 
Mueller's  ducts  has  failed  in  development  from  the  uterus  down,  and 
the  other  has  developed  only  on  its  own  side,  producing  a  unilateral 
vagina.  In  case  of  double  uterus,  or  uterus  septus,  or  uterus  bicornis, 
one-half  of  the  vagina  may  be  imperforate,  with  resulting  accumulation 
of  menstrual  blood  in  the  uterus  and  vagina  on  that  side  (hsematometra 
and  hgematocolpos) .    Chapter  XXXV. 

Aside  from  the  possibilities  of  sterility  and  hsematocolpos,  and  from 
the  uterine  conditions  which  may  be  associated,  a  vaginal  septum  is 
not  of  itself  a  very  serious  matter.  It  may  never  be  suspected  until 
parturition,  and  even  then  the  septum  may  be  destroyed  or  pushed  to 
one  side  by  the  passing  child. 

Complete  Absence  of  the  Vagina  usually  is  associated  with  absence 
or  defect  of  the  ovaries,  tubes,  and  uterus,  and  with  a  generally  defec- 
tive sexual  organization.  If,  however,  the  defect  is  only  in  that  part 
of  Mueller's  ducts  which  forms  the  vagina,  the  uterus  and  tubes  may 
be  developed  normally.  Absence  of  the  vagina  then  will  lead  after 
puberty  to  retention  of  the  menstrual  products  and  the  necessity  of 
making  an  artificial  vaginal  passage  in  order  to  give  exit  to  retained 
menstrual  fluid,  and  otherwise  to  establish  the  physiological  integrity 
of  the  vagina.    Impregnation  and  parturition  have  taken  place  through 

1  Reported  by  Suppioger.     Allbutt  and  Playfair,  System  of  Gynecology. 


MALFORMATIOSS  OF   THE    V ILV A    AND   AWH  503 

a  vagina  tliiis  opciu-d.  This  siil)jwt  will  he  considered  further  in  the 
next  chapter. 

Inflammatory  Atresia  of  the  Vagina  must  not  be  confounded  with 
con^fiiital  absence  of  the  organ.  The  former  is  the  result  of  adhesive 
intiannnations  which  may  be  foetal  and  involve  the  whole  length  (jf 
the  passage,  or  it  may  be  due  to  inflannnation  occurring  in  childhood 
or  in  adult  life;  see  Dissecting  Vulvovaginitis.  In  a  case  of  adherent 
vaginal  walls,  the  walls  when  separated  wherever  the  inflammation 
has  not  been  destructive  will  retain  the  vaginal  mucosa.  In  congenital 
absence  of  the  vagina  the  mucosa  never  has  developed.  There  is  only 
connective  tissue  between  the  \'esical  and  rectal  walls. 

Other  Anomalies  of  the  Vagina. — The  remaining  vaginal  anomalies 
are  rare;  they  include  diverticula  and  communications  between  the 
vagina  and  other  organs,  such  as  the  rectum  and  urethra.  These 
openings  are  dependent  not  upon  defects  of  Mueller's  ducts,  but 
rather  upon  foetal  cloacal  conditions,  hereafter  to  be  described. 


MALFORMATIONS    OF   THE   HYMEN 

The  hymen  is  an  organ  of  variable  strength  and  form.  It  may  be 
annular,  notched,  fimbriated,  fenestrated,  cribriform,  crescentic,  thick, 
thin,  fragile,  tough,  or  vascular.  Some  of  these  conditions  are  normal, 
others  but  slightly  abnormal.  Complete  absence  is  extremely  rare,  if 
not  unknown.  Imperforation,  so-called,  is  a  condition  usually  due  to 
closure  of  the  end  of  a  Muellerian  duct. 

The  importance  of  these  anomalous  conditions  varies.  A  rigid 
hymen  makes  coitus  painful  or  impossible,  a  very  vascular  membrane 
may  lead  to  a  temporary  profuse  hemorrhage,  and  imperforation  gives 
rise  to  hsematocolpos,  or  in  extreme  cases  also  to  hsematometra,  and 
demands  operative  interference;  see  Congenital  Atresia  of  the  Genital 
Tract.    A  rigid  h^Tuen  may,  after  marriage,  require  divulsion  or  incision. 


MALFORMATIONS    OF   THE   VULVA    AND    ANUS 

This  subject  becomes  relatively  simple  when  we  understand  the 
embryological  development  of  the  \\i\\a.  and  anus.  At  the  end  of 
the  sixth  week  of  foetal  life  the  tangible  differentiation  of  sex  begins, 
and  the  developmental  changes  which  then  normally  take  place  are 
shown  in  Figures  235  to  239.  The  student  is  referred  to  the  embryology 
of  the  genitalia  in  the  first  part  of  this  chapter. 

At  first  the  allantois  (which  forms  the  bladder),  the  rectum,  and  the 
Muellerian  ducts  (which  form  the  vagina,  uterus,  and  Fallopian  tubes) 
all  communicate  with  a  common  cavity,  but  do  not  at  this  time  open 
on  the  external  surface.  Presently  there  is  a  depression  in  the  skin 
which  opens  inward  to  this  cavity,  thus  forming  the  cloaca.  The 
cloacal  opening  is  divided  now  into  two  parts  by  a  septum,  which  later 


Figure  236 


Figure  235. — R,  rectum,  continuous  with  All,  allantois  (bladder),  and  M,  duct  of  Mueller  (vagina). 
A ,  depression  of  skin  below  genital  prominence,  which  grows  inward  and  forms  vulva. 

Figure  236. — The  depression  has  extended  inward  and,  becoming  continuous  with  the  rectum 
and  allantois,  forms  the  cloaca.     CI,  cloaca;  B,  bladder;  V,  vagina;  R,  rectum. 


Figure  237 


Figure  238 


Figure  237. — The  cloaca  is  becoming  divided  into  the  urogenitd  sinus,  SU,  and  anus.  A,  by  the 
downward  growth  of  the  penneal  septum.  When  this  downward  growth  is  incomplete  the  condition 
IS  called  persistent  cloaca. 

Figure  238. — The  perineum  is  completely  formed.  P,  perineum.  The  ducts  of  Mueller  have 
united  the  lower  portion  forming  the  vagina. 


Figure  239 


The  upper  part  of  the  urogenital  sinus  has  contracted  into  the  urethra;  the  lower  portion,  SU,  now 
becomes  the  vulva;  P,  perineum;  R,  rectum;  V,  vagina;  B,  bladder;  U,  urethra.' 


Figure  240. — Absence  of  cloacal  division.    Perineal  septum  wanting,    it!,  rectum;  G,  genital  canal: 
B,  bladder. 

Figure  241. — Absence  of  cloacal  division.     Perineal  septum  present. 

(504) 


MM.rORMATIOXS  OF   THE    Vri.VA    AM)   AXIS 


505 


develops  into  the  perineum.  Tlie  posterior  portion  oF  the  eloaea  tlnis 
(li\i(le(l  l)eeomes  the  anus.  The  anterior  part  heecjnies  the  urof^enital 
sinus.  This  sinus  in  its  ui)iht  part  heeomes  the  urethra,  and  in  its 
lowtT  part  the  vuKa.  The  aiioniahes  of  the  \ul\a  anrl  anus  are: 
Atresia;  persistent  eh)aea;  iiypospadias;  epi.spadias;  infantile  vulva. 


Figure  242 


FiGtKE   24.5 


Fjgure  242. — Building  of  a  urethra.  Author's  operation.  Congenital  absence  of  urethra.  Black 
and  white  dotted  lines  indicate  area  to  be  denuded  in  the  construction  of  a  new  urethra.  In  a  recent 
operation,  instead  of  denuding  I  simply  made  a  semicircular  incision  and  separated  the  incised  margins 
to  the  width  of  the  denudation  and  otherwise  proceeded  as  shown  in  the  figures.  The  result  was  more 
satisfactory  than  in  previous  cases  in  which  valuable  tissue  was  sacrificed  by  denudation. 

FiGCRE  243. — Building  of  a  urethra.  Author's  operation.  Same  as  Figure  242.  .\rea  for  construc- 
tion of  a  new  urethra  denuded.  Inner  margins  of  denuded  area  being  brought  together  by  continuous 
catgut  sutures  so  as  to  unite  those  margins  over  the  sound,  which  has  been  introduced  into  the  bladder 
and  is  held  by  the  hand  of  an  assistant. 

Atresia  of  the  Urethra,  Vagina,  and  Anus. — The  cloacal  division 
by  which  the  urethra,  vagina,  and  anus  are  opened  and  thereby  pro- 
longed to  the  external  surface  may  fail  to  take  place.  This  failure 
will  result  in  complete  atresia  of  the  vagina,  urethra,  and  anus.  The 
perineal  septum  may  be  absent,  as  shown  in  Figure  240,  or  present 
as  shown  in  Figure  241.  In  the  latter  case  the  opening  between  the 
rectum  and  the  urogenital  sinus  will  be  closed.  This  condition  of  com- 
plete atresia  has  been  observed  only  in  stillborn  foetal  monstrosities. 
The  bladder,  urethra,  and  vagina — that  is,  the  urogenital  sinus^are 
apt  to  be  distended  with  urine. 

Congenital  atresia  is  not  to  be  confounded  with  another  form  of 
vulvar  atresia  in  which  the  labia  have  become  adherent  from  inflamma- 
tion. Tliis  adhesion  may  occur  before  or  after  birth.  The  adhesion 
31 


506 


TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 


is  generally  incomplete,  so  that  urine  and  menstrual  fluid  can  escape. 
The  condition  has  been  designated  superficial  atresia  of  the  vulva;  it 
may  be  remedied  by  separating  the  labia,  either  by  divulsion  or  by 
cautious  dissection. 


Figure  244 


Figure  245 


Figure  244. — Building  of  a  urethra.  Author's  operation.  Same  as  Figure  243.  ^largins  of  new 
urethral  mucosa  united  over  the  sound  b.v  fine  continuous  chromic  catgut  suture.  The  first  stitch 
has  been  introduced  and  tied,  and  the  needle  is  being  introduced  for  the  second  stitch  to  unite  the 
outer  margins  of  the  denuded  area  for  the  completion  of  the  new  urethra. 

Figure  245. — Building  of  a  urethra.  Author's  operation.  Same  as  Figure  244.  Sound  in  positioa 
as  in  Figures  243  and  244.  Last  stitch  of  a  continuous  suture  being  introduced.  This  stitch  when 
tied  will  complete  the  formation  of  the  new  urethra. 


Persistent  Cloaca. — In  this  anomaly  the  anus  practically  opens 
directly  into  the  vestibule;  there  is  no  perineum.  The  anomaly  is  a 
persistence  of  the  condition  in  Figure  237.  If  the  anal  sphincter  is 
also  deficient,  the  condition  is  a  pitiable  one.  When  there  is  control 
over  the  feces  an  operation  may  not  absolutely  be  needed;  but  when 
there  is  incontinence  of  feces  it  is  always  advisable,  and  preferably 
before  maturity.  The  usual  operation  has  been  to  pass  a  probe  into 
the  fistula  and  out  at  the  normal  position  of  the  anus,  then  split  up 
the  parts,  draw  the  rectum  downward  and  backward  to  the  angle 
of  the  incision,  suture  it  into  position,  and  close  the  gap  in  front.  A 
modification  of  this  operation  has  been  suggested  by  Buckmaster;  in 
this  modification  the  new  anus  is  made  first  just  in  front  of  the  levator 
ani  muscle,  and  at  a  later  period  the  fibres  of  this  muscle  are  split  to 
make  a  sphincter. 


MALFORMATIOXS  OF   THE   VULVA    AND  ANUS  507 

Hypospadias  in  the  female  is  a  defect  in  the  posterior  wall  of  the 
urethra,  or  in  extreme  cases  entire  absence  of  the  urethrovaginal 
wall,  with  resulting  incontinence  of  urine  as  in  a  vesicovaginal  fistula. 
The  malformation  is  a  continuation  of  the  fci'tal  condition,  shown 
in  Figure  237,  and  it  is  due  to  persistence  of  the  urogenital  sinus.  The 
lower  portion  of  the  allantois  has  failed  partially  or  completely  at 
development  into  a  uretlira.  In  marked  cases  there  is  incontinence,  but 
in  slight  cases  there  may  be  control  of  urine.  Ilypertn^phy  of  the 
clitoris  is  apt  to  be  an  associated  defect.  Sometimes  the  clitoris  may 
be  large  enough  to  raise  the  question  as  to  the  sex  of  the  individual.  A 
condition  resembling  hypospadias  may  result  from  traumatism — that  is, 
the  urethrovaginal  wall  may  be  surgically  divided,  or  may  slough  out 
in  consequence  of  pressure  necrosis  following  labor.  Whatever  the  cause 
of  the  condition  may  be,  if  there  is  incontinence  of  urine,  a  plastic 
operation  should  be  made  to  construct  an  artificial  urethra.  Emmet 
was  the  principal  pioneer  in  this  operation.  His  method  was  to  utilize 
the  labia  minora  as  material  out  of  which  to  make  the  new  urethra. 
He  denuded  a  longitudinal  strip  on  the  inner  surface  of  each  labimn,  and 
then  united  them  by  means  of  interrupted  sutiu-es,  and  in  this  way 
was  successful  in  securing  more  or  less  retentive  power.  The  author 
has  for  several  years  employed  a  somewhat  different  method  with 
gratif^'ing  results.  This  method  is  illustrated  in  Figures  242  to  245. 
Here  observe  especially  the  substitution  of  flap-splitting,  by  incision,  for 
denudation. 

It  is  important  in  building  lip  a  new  urethra  to  have  in  mind  three 
special  points :  first,  to  introduce  the  sutures  over  a  rather  small  sound, 
for  the  urethra  will  usually  dilate,  and,  if  a  large  sound  is  used,  will 
therefore  finally  become  too  wide;  second,  broad  areas  of  denudation 
should  be  made  on  each  side  so  as  to  produce  a  very  thick  urethro- 
vaginal wall,  for  this  wall  usually  grows  thinner  by  stretching  or  absorp- 
tion and  therefore  should  be  quite  thick  to  begin  with;  third,  before 
the  new  lu-ethra  is  attempted  an  artificial  vesicovaginal  fistula  should 
be  made  midway  between  the  inner  extremity  of  the  urethra  and  cer\'ix 
uteri,  so  that  diu-ing  the  healing  process  the  sutures  in  the  new  urethra 
may  not  be  disturbed  mechanically  by  the  outflow  of  urine.  After 
union  in  the  urethra  has  become  solid  the  fistula  may  be  closed  in  the 
usual  fashion. 

The  artificial  vesicovaginal  fistula  should  be  made  as  d'^scribed  in  the 
treatment  of  cystitis.  Chapter  XXI. 

Epispadias  in  woman  is  a  defect  in  the  upper  wall  of  the  m-ethra, 
and  generally  is  accompanied  with  fissure  of  the  clitoris,  and  some- 
times also  \\'ith  fissure  of  the  SATuphysis  pubis  and  of  the  whole  anterior 
vesical  wall.  This  gives  rise  to  ectropion  of  the  bladder.  Incontinence 
of  urine  occurs  even  in  the  slighter  forms,  and  an  operation  is  required 
to  restore  the  integrity  of  the  bladder-wall.  The  labia  are  commonly 
absent  in  extreme  forms  of  epispadias. 

Infantile  Vulva. — General  lack  of  development  of  the  vulva  and 
absence  of  the  labia  majora  and  minora  are  associated  commonly  with 


508  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

defects  of  the  internal  genital  organs  and  with  a  generally  weak  systemic 
development,  and  often  coexist  with  chlorosis.  They  are  not  an  abso- 
lute impediment  to  impregnation,  but  may  be  to  parturition. 

MALFORMATIONS    OF   THE   NYMPHS,    CLITORIS,    AND 

PREPUCE 

Hypertrophy  of  the  Nymphae  has  been  much  observed  in  the  lower 
races,  especially  among  the  African  tribes.  It  is  said  also  to  be  found 
frequently  in  connection  with  hypertrophy  of  the  mammae  among  the 
American  Indians.  See  Elephantiases.  The  nymphse  may  become 
so  large  as  to  require  removal. 

Hypertrophy  of  the  Clitoris. — The  clitoris  will  be  recalled  as  that 
organ  in  the  female  which  corresponds  to  the  penis  in  the  male.  Hyper- 
trophy of  the  clitoris  may  be  congenital  or  acquired.  Congenital 
hypertrophy  is  associated  not  uncommonly  with  other  malformations, 
such  as  pseudohermaphrodism,  and  may  be  so  excessive  as  to  give  the 
clitoris  the  appearance  of  a  penis.  The  anomaly  occurs  more  frequently 
in  the  tropics  than  in  temperate  zones.  Congenital  enlargement  of 
the  clitoris  is  an  indication  for  removal  (clitorectomy) .  Acquired 
enlargement  is  associated  usually  with  masturbation,  but  unfortunately 
excision  does  not  usually  put  an  end  to  the  habit.  In  two  cases  of 
uncontrollable  erotic  paroxysms  occurring  in  the  author's  practice,  in 
which  the  clitoris  appeared  to  be  the  storm-centre,  but  in  which  there 
had  been  no  masturbation,  excision  of  the  clitoris  was  followed  by 
relief.  This  operation,  clitorectomy,  since  the  career  of  the  "brilliant 
and  blighted  Baker  Brow^n"  is  almost  obsolete,  the  indications  for  it 
being  very  restricted. 

Acquired  hypertrophy,  usually  the  result  of  masturbation  in  child- 
hood, does  not  produce  great  enlargement. 

Hypertrophy  of  the  Prepuce. — There  is  a  class  of  cases  occasionally 
observed  among  children  in  which  the  clitoris  is  enlarged  moderately 
and  surrounded  by  an  abundance  of  loose,  flabby,  redundant  preputial 
skin.  In  such  cases  the  causes  may  be  both  congenital  and  acquired. 
The  congenitally  h\'pertrophied  clitoris  and  redundant  prepuce  are, 
by  reason  of  their  size,  unduly  exposed  to  friction;  this  gives  rise  to 
irritation;  the  child  instinctively  rubs  or  scratches  the  part  in  order 
to  obtain  relief,  and  thus  gradually  forms  the  habit  of  masturbation 
This  frequent  counterirritation  and  consequent  congestion  are  then  in 
themselves  additional  causes  of  enlargement  of  the  clitoris,  and  especially 
of  redundancy  of  the  prepuce.  The  child,  unless  relieved  of  the  local 
irritation  and  taught  to  avoid  all  friction  of  the  part,  soon  becomes  a 
hopeless  neurotic.    The  treatment  in  such  a  case  is  circumcision. 

The  technique  of  circumcision,  which  closely  resembles  that  of  circum- 
cision in  the  male,  is  set  forth  in  Figures  246  to  249.  In  the  operation 
the  same  careful  trimming  of  the  loose,  redundant  skin  is  necessary 
as  in  circumcision  of  the  male  child.  In  suitable  cases  the  operation, 
if  supplemented  by  positive  and  proper  moral  instruction  and   by 


MALFORMATIONS  OF  NYMPH.E,   CLITORIS,   AND  PREPUCE     TjOO 

judicious  hygiene,  may  be  followed  hy  a  cure  oF  the  unfortunate  habit 
and  by  relief  from   uitnous  sym])toms.     A  most  im])ortant  faetor  in 


Fkjiue  21G 


Figure  248 


Figure  249 


Figure  246. — Circumcision  in  the  female.  Redundancy  of  the  prepuce  and  enlargement  of  the 
clitoris  in  a  masturbating  girl  of  eleven.  Appearance  of  prepuce  when  put  upon  the  stretch.  The 
scissors  are  di\ading  the  prepuce  on  the  dorsum,  as  they  would  in  circumcision  of  the  male  prepuce. 

FiGUBE  247. — Same  as  Figure  246.  Right  half  of  the  divided  prepuce  hanging  loose  with  forceps 
attached.     Left  half  being  removed  with  scissors.     Right  half  also  to  be  removed  in  same  way. 

Figure  248. — Same  as  Figure  247.  Redundant  portion  of  prepuce  all  removed.  Raw  surfaces 
exposed.     Margins  of  wound  being  brought  together  by  means  of  interrupted  fine  catgut  sutures. 

Figure  249. — Same  as  Figure  248.     Last  suture  is  being  introduced,  completing  the  operation. 


the  general  treatment  is  hygiene,  that  is,  a  non-nitrogenous  diet,  the 
avoidance  of  sweets,  spices,  highly  seasoned  food,  tea,  coffee,  and 
stimulating  drinks.    Circumcision  often  may  be  advantageously  supple- 


510  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

merited  by  removal  of  the  nymyha  if  they  are  enlarged  and  give  rise  to 
mechan  ical  irritation . 

Adherent  Prepuce. — Adhesion  of  the  prepuce,  which  may  be  con- 
genital or  acquired,  produces  the  same  reflex  nervous  symptoms  in 
the  male,  and  requires  the  same  treatment — that  is,  separation  of  the 
prepuce  from  the  glans  by  breaking  up  the  adhesions  or  by  incision.  In 
some  cases  the  indication,  after  loosening  the  adhesion,  is  to  slit  up 
the  prepuce  on  the  dorsum.  If  the  prepuce  is  not  so  redundant  as  to 
require  removal,  the  wound  as  in  the  corresponding  operation  in  the 
male  may  be  reunited  by  a  line  of  union  at  right  angles  to  the  line  of 
incision. 

HERMAPHRODISM 

If  we  use  the  word  hermaphrodism  in  the  strict  sense,  to  signify  a 
combination  of  anatomically  and  functionally  perfect  male  and  female 
organs  in  one  individual,  a  typical  case  has  never  been  established 
satisfactorily.  The  condition  occurs  sometimes  in  the  higher,  but 
more  frequently  in  the  lower  vertebrates,  and  it  is  perhaps  possible 
in  man,  but  thus  far  has  not  been  demonstrated  by  the  necessary 
autopsy. 

The  cases  of  so-called  hermaphrodism  all,  or  nearly  all,  fall  under 
the  head  of  yseudoherinaphrodism,  in  which  there  may  be  an  irreg- 
ular development  of  the  sexual  organs,  some  of  the  female,  others  of 
the  male  type,  but  with  a  decided  predominance  of  one  over  the  other. 
If  the  individual  is  really  a  female,  and  resembles  the  male,  the  mal- 
formation is  called  Gynandry;  if  the  male  resembles  the  female,  it  is 
Androgyny.  See  Figure  250,  which  is  presented  here  as  a  modification 
of  a  drawing  by  Zweifel. 

Gynandry. — There  are  two  classes  of  cases. 

In  one  class  the  breasts  approach  or  conform  to  the  male  t>T3e.  There 
may  also  be  a  hairy  development  on  the  face  and  a  masculine  voice, 
contour,  and  appearance.  The  genitalia,  although  perhaps  rudimentary, 
are  yet  unmistakably  of  the  female  t}T)e.  There  may  be  congenital 
atresia  of  the  vagina  and  an  infantile  vulva,  but  the  uterus  and  ovaries, 
partly  or  fully  developed,  are  present. 

In  the  other  class  of  cases  the  hairy  development  and  masculine 
voice,  contour,  and  appearance  are  supplemented  by  one  or  more  of 
the  following  anomalies: 

a.  Pronounced  hypertrophy  of  the  clitoris,  sometimes  to  the  size 
and  appearance  of  the  fully  developed  penis. 

h.  The  labia  minora  and  majora  may  be  fused  together  so  as  to 
obliterate  the  vulvar  entrance. 

c.  Ovarian  hernia  and  a  consequent  pouch  may  be  present,  resem- 
bling in  form  and  situation  a  scrotum  with  its  testicles.  The  uterus 
and  ovaries  are  developed  more  or  less  perfectly. 

Androgyny. — Most  of  the  cases  of  pseudohermaphrodism  occur  in 
individuals  who  have  testicles,  and  are  therefore  essentially  male. 
There  are  several  forms  of  this  class,  of  which  three  are  given  below: 


UERMAPnRODI><M 


511 


1.  The  mildest  form  is  that  in  which  the  breasts  approach  or  con- 
form to  the  female  tyi)e,  and  the  penis  and  testicles  are  correct  in 
form,  but  rudimentary. 

2.  An  interesting;-  subdivision  of  androgyny  includes  individuals 
whose  generative  organs  are  apparently  female,  except  that  they  have 
testicles  instead  of  ovaries,  these  glands  being  situated  in  the  abdomen 
or  in  the  inguinal  canal,  and  the  scrotum  being  absent.  The  clitoris, 
vulva,  vagina,  and  uterus,  more  or  less  imperfectly  developed,  are 
present.  Individuals  belonging  to  this  subdivision  are  usually  brought 
up  and  pass  as  women  throughout  their  lives. 


Figure  250 


Pseudohermaphrodism  by  hypospadias  (male). 
C,  undeveloped  penis,  resembling  large  clitoris; 
iJ,  rectum. 


T,  testicles,  not  descended;  S,  symphysis  pubis; 
B,   bladder;    V,   prostatic   vesicle   (pseudovagina); 


3.  The  most  numerous  subdivision  is  that  of  hypospadia  men.  There 
is  an  imperfect,  diminutive  penis  held  down  by  a  bridle,  and  having 
the  appearance  of  a  large  clitoris.  The  pendulous  portion  of  this  penis 
is  imperforate.  The  hypospadiac  urethral  opening  corresponds  in  situ- 
ation and  appearance  to  the  female  urethra.  The  testicles  are  usually 
in  the  abdomen  or  inguinal  canal,  and  the  scrotum  is  wanting.  There 
is  a  fissure  in  the  median  perineal  raphe — a  perineoscrotal  fissure. 
The  development  on  either  side  of  this  fissure  resembles  the  vulvar 
labia.  These  individuals  have  the  female  mammary  development, 
usually  are  brought  up  as  girls,  and  in  some  instances  have  discovered 
the  mistake  only  after  marriage.  Intercourse  may  be  possible  either  in 
the  prostatic  vesicle,  see  Figure  250,  or  in  the  dilated  urethra.  Some  of 
these  monstrosities  have  been  capable  of  coitus  both  as  men  and  women. 


512  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

The  importance  of  hermaphrodism  is  obvious.  As  a  clear  diagnosis 
of  sex  in  doubtful  cases  cannot  always  be  made  at  birth,  it  is  suggested 
that  in  cases  of  doubt  the  individual  should  be  brought  up  as  a  boy. 
This  course  will  cause  less  embarrassment,  and  in  the  vast  majority 
of  cases  w^ill  prove  to  be  correct. 

Treatment  of  Hermaphrodism 

The  treatment  of  hermaphrodism  is  limited  to  those  cases  in  which 
anatomical  defects  can  be  corrected  by  operative  measures.  The  labia, 
if  fused  together,  may  be  separated  by  breaking  the  adhesions  or  by 
incision.  The  hypertrophic  clitoris  or  labia  may  be  removed  and  the 
wounded  surfaces  covered  by  a  plastic  operation. 

The  bridle  or  frsenum  holding  down  the  penis  in  androgyny  may 
require  an  operation  for  the  liberation  of  the  organ,  and  plastic  work 
for  the  covering  of  the  exposed  surfaces. 

Epispadias  and  pseudohermaphrodism  may  furnish  indications  for 
operative  measures,  and  if  so,  must  be  treated  in  each  case  according 
to  special  requirements. 


CHAPTER   XXXIV 

CONGENITAL  GYNATRESIA  WITH  RETAINED  IMENSTRUAL 

FLril) 

Atresia  in  the  genital  tract  of  a  menstruating  woman  is  apt  to 
result  in  retention  of  menstrual  fluid  above  the  point  of  obstruction. 
The  fluid  thus  retained,  of  a  tar-like  color  and  consistence,  contains 
blood,  mucus,  and  epithelial  debris. 

Figures  251  to  262,  suggested  by  and  modified  from  a  scheme  of 
Sutton  and  Giles,  show  the  accumulations  of  menstrual  fluid  which 
may  take  place  above  the  various  possible  points  of  atresia  in  the 
uterus,  vagina,  or  vulva.  The  accumulations  come  under  one  of  the 
three  following  divisions: 

1.  An  accumulation  in  the  vagina  will  take  place  above  the  point 
of  vaginal  or  vulvar  atresia,  and  is  called  hopmatocolpos. 

2.  An  accumulation  in  the  uterus  call  hcEinatometra  is  limited  below 
according  as  the  atresia  is  at  the  internal  or  external  os,  in  the  corpus 
or  in  the  cervix  uteri.     A  distended  cervix  is  called  hsematotrachelos. 

3.  The  uterus  having  been  distended,  the  blood  may  force  its  way 
into  and  distend  the  Fallopian  tubes,  producing  hcematosalpinx.  The 
fimbriated  extremity  in  such  cases  usually  is  closed  by  adhesive 
inflammation.  Hsematosalpinx  due  to  retention  of  menstrual  blood 
is  associated  usually  with  haematometra. 

Hsematocolpos  may  exist  alone  or  may  be  associated  with  haemato- 
metra and  hsematosalpinx. 

The  Pathological  Results 

The  pathological  results  are  primarily  those  of  pressure  upon  the 
mucosa,  and  distention  and  thinning  of  the  walls  of  the  dilated  organs; 
this  leads  to  atrophy  of  the  mucosa  and  muscularis.  Secondarily,  there 
may  be  infection  and  consequent  admixture  of  pus  with  blood;  the 
conditions  may  then  be  termed  pyocolpos,  pyometra,  and  pyosalpinx. 

Symptoms  of  Congenital  Gynatresia 

The  symptoms  are  commonly  absent  until  puberty;  at  this  time 
menstruation  first  begins  and  gives  rise  to  accumulations  of  men- 
strual blood.  The  young  girl  will  then  have  the  symptoms  of  monthly 
recurring  menstruation  called  the  molimen,  with  a  sense  of  superadded 
weight  and  heaviness  due  to  accumulations  of  menstrual  fluid.  The 
sense  of  weight  will  increase  vrith  the  quantity  of  fluid,  and  in  cases 

(ol3) 


514  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS 

of  extreme  hgematometra  will  become  excessive,  and  may  resemble 
labor-pains.  There  may  also  be  distressing  pressure  on  the  adjacent 
organs.  Suppuration,  if  present,  gives  rise  to  the  same  symptoms  of 
absorption  as  would  result  from  an  abscess. 

Diagnosis  of  Congenital  Gynatresia 

The  physical  signs  will  reveal  a  fluctuating  elastic  tumor  correspond- 
ing to  the  seat  and  extent  of  the  accumulations.  The  tumor,  if  in  the 
vagina,  will  be  felt  most  distinctly  in  that  region,  and  may  bulge 
between  the  labia ;  if  in  the  uterus  and  tubes,  it  will  easily  come  mthin 
reach  of  the  external  hand  on  conjoined  examination,  and  fluctuation 
will  be  distinct  on  palpation  between  the  vagina  and  hypogastrium. 

Figure  251  Figure  252 


Figure  251. — Atresia  at  the  vulva  first  causes  distension  of  the  vagina,  producing  hsematocolpos. 
Figure  252. — Atresia  at  the  vulva.     Hsematotrachelos  has  followed  hiEmatocolpos. 

The  distended  tubes  are  made  out  usually  to  either  side  of  the  distended 
uterus.  Conjoined  examination  with  the  left  index-finger  in  the  rectum 
may  give  further  information.  The  finger  in  the  rectum  and  the  sound 
in  the  bladder  sometimes  will  define  the  upper  limits  of  hsematocolpos. 

If  the  atresia  is  at  the  os  internum,  it  gives  rise  to  no  change  in  the 
form  of  the  cervix,  but  gives  to  the  corpus  uteri  the  appearance  of 
pregnancy. 

One  side  of  a  double  vagina  or  uterus  may  be  distended  and  the  other 
side  empty.  There  will  then  be  a  tumor  on  the  affected  side  and  lateral 
displacement  by  pressure.  The  symptoms,  supplemented  by  con- 
joined examination  and  the  sound,  will  be  the  means  of  diagnosis. 
The  groove  between  the  distended  and  empty  sides  may  be  felt  on 
rectal  touch. 


COXGEXI TA  L   G  YXA  TRESIA 


515 


Hsematometra  is  distinguished  from  pregnancy  by  the  absence  of 
the  usual  signs  of  pregnancy,  especially  of  discoloration,  patulous  os 


FiouBE  253 


Figure  254 


FiGCRE  253. — Atresia  at  the  vulva  has  caused  haematocolpoa,  then  haematotrachelos,  and  then 

haematometra.  .     r^-          „.„     ,         •      jj  j 

Figure  254. — Atresia  at  the  vulva.  In  addition  to  the  conditions  in  Figure  2o3,  there  is  added 
haematosalpinx. 


Figure  255 


Figure  256 


FiGUKE  255. — Atresia  in  the  vagina  midway  between  the  vulva  and  os  externum;  causing  hsema- 
tocolpos  in  the  upper  half  of  the  vagina.  ,^1.1..  u       f  11 .a  *k« 

Figure  256. — Same  as  in  Figure  255,  except  that  distension  of  the  whole  uterus  has  followed  the 
partial  haematocolpos. 

externum,  and  vaginal  pulsation.     Hsematocolpos  or  hsematometra  on 
one  side  of  a  double  uterus  or  vagina  may  lead  to  great  confusion. 


516  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS 

Conjoined  examination  and  the  history  of  the  case  will  serve  to  dis- 
tinguish the  former  from  extra-uterine  pelvic  tumors,  and  the  latter 
from  abscess  or  cyst  of  the  vaginal  wall. 

Figure  257  Figure  258 


Figure  257. — Atresia  at  the  os  externum  producing  a  heematotrachelos.  Corpus  uteri  not  yet 
distended.  . 

Figure  258. — Atresia  at  the  os  internum  producing  haematometra.  Fallopian  tubes  may  become 
distended  later. 

Figure  259  Figure  260 


Figure  259. — Atresia  at  the  vulva  on  one  side  of  a  double  uterus  and  vagina,  causing  hsemato- 
colpos  on  affected  side. 

Figure  260. — Atresia  on  one  side  of  double  uterus  and  vagina  midway  between  viilva  and  os 
externum.     This  produces  partial  haematocolpos  of  affected  side. 

The  greatest  care  in  manipulation  is  essential  lest  the  sac  rupture 
and  discharge  its  contents  into  the  peritoneum,  or  the  fluid  be  forced 
through  the  Fallopian  tubes.     The  fluid,  however,  is  apt  to  be  sterile. 


(  OXCEMTA L  G YSA TRESIA 


517 


Prognosis  of  Congenital  Gynatresia 

Unless  relief  conies  from  operation,  tiie  thin  walls,  especially  of  the 
Fallopian  tubes,  may  rupture  and  set  up  peritonitis.  Suppuration 
may  give  rise  to  the  phenomena  incident  to  pelvic  abscess.  If  the 
sac  ruptures  into  the  intestine,  infection  and  death,  or  a  precarious 
recovery  may  follow. 

Treatment  of  Congenital  Gynatresia 

The  treatment  is  free  incision  at  the  point  of  atresia,  evacuation  of 
accumulated  fluids,  washing  out  and  drainage  of  the  cavity.  There  is 
in  these  cases  an  unexplained  and  excessive  liability  to  postoperative 
infection.  Extra  care  therefore  in  the  asepsis  before,  during,  and  after 
the  operation  is  imperative. 


Figure  261 


Figure  262 


Figure  261. — Atresia  on  one  side  of  double  uterus  and  vagina  at  \-ulva,  producing  hsmatocolpos, 
hsematotrachelos,  and  haematometra. 

Figure  262. — Atresia  on  one  side  of  double  uterus  and  vagina  at  os  externum,  producing  hama- 
totrachelos  and  hsematometra. 

Operations  for  Haematometra  will  vary  according  to  the  location 
and  extent  of  the  atresia.  In  some  cases  the  obstruction  is  slight  and 
easily  broken  by  a  sound  or  by  pushing  a  pair  of  blunt-pointed  scissors 
or  forceps  through  it,  and  spreading  the  blades  to  secure  the  necessary 
divulsion  and  dilatation.  The  canal  once  opened  should  be  made  to 
remain  patulous,  if  necessary,  by  immediate  free  incision  or  dilatation. 
The  atresia  may  be  at  the  internal  or  external  os,  or  the  whole  cervical 
canal  may  be  obliterated.  In  the  latter  case  it  is  sometimes  necessary 
to  separate  the  bladder  from  the  uterus  as  in  anterior  vaginal  section. 
The  separation  does  not  necessarily  extend  into  the  peritoneum,  but 
should  be  carried  past  the  level  of  the  internal  os.  The  anterior  wall 
of  the  uterus  may  then  be  divided  longitudinally  with  scissors  until  the 


518  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS 

interior  of  the  corpus  is  reached  and  evacuated.  The  opening  thus 
made  is  rendered  permanent  by  additional  incision,  gauze  packing, 
dilatation,  plastic  surgery,  or  all  these  combined. 

Hsematometra  may  occur  with  complete  or  nearly  complete  absence 
of  the  vagina.  See  Malformations  of  the  Vagina.  Under  these  con- 
ditions the  choice  of  procedure  is  between: 

1.  Artificial  vagina. 

2.  Abdominal  hysterectomy  or  removal  of  the  uterine  appendages. 

1.  Artificial  Vagina  consists  in  separating  the  vesical  from  the  rectal 
plate  of  the  rectovaginal  septum  and  entering  and  evacuating  the 
uterus  through  the  canal  thus  made.  First,  the  incision  is  made  freely 
from  side  to  side  through  the  vulvar  skin;  the  two  plates  of  the  recto- 
vesical septum  then  are  split  readily  apart  by  means  of  the  two  index- 
fingers,  which  easily  work  their  way  through  loose  cellular  tissue  to 
the  uterus.  The  uterus,  if  present,  will  be  recognized,  when  reached, 
by  its  relative  hardness  and  resistance,  and  sometimes  by  the  elasticity 
and  sense  of  fluctuation  of  retained  fluid,  and  may  be  opened  by  means 
of  the  sharp-pointed  scissors,  using  as  a  guide  the  aspirator  needle 
previously  introduced.  In  working  his  way  to  the  uterus,  the  operator 
may  avoid  entering  the  bladder  or  rectum  by  frequently  introducing 
the  finger  into  the  rectum  and  the  sound  into  the  bladder.  Emmet 
says  that  in  some  cases  the  new  vagina  when  it  heals  over  the  glass 
vaginal  dilator  is  covered  by  a  structure  not  altogether  unlike  mucous 
membrane,  and  that  after  healing  has  taken  place  the  frequent  use  of 
the  glass  dilator  will  keep  the  vagina  open.  The  writer's  experience 
in  three  cases  personally  observed  is  that  no  such  membrane  formed;, 
but  that,  on  the  contrary,  the  surfaces  were  entirely  cicatricial  or 
granulating  in  character. 

It  is  desirable  as  soon  as  the  vagina  has  been  opened  to  cover  it 
with  skin  flaps  dissected  from  the  external  genitals.  The  labia  minora 
frequently  are  utilized  for  this  purpose.  C.  K.  Fleming^  has  published 
an  improvement  on  the  above  method.  Before  splitting  the  recto- 
vesical septum  he  dissects  loose  a  long  wide  flap  composed  of  the  hymen, 
the  posterior  ends  of  the  nymphse  and  the  upper  part  of  the  perineal 
integument,  leaving  the  upper  part  of  the  flap  attached,  and,  after 
splitting  the  septum,  he  utilizes  this  flap  for  the  anterior  vaginal  wall. 
He  then  dissects  a  flap  from  the  labium  majus  on  one  side,  leaving  the 
lower  part  attached  for  the  posterior  vaginal  wall.  After  splitting  the 
septum  these  flaps  are  stitched  into  the  new  vagina,  so  as  to  make  them 
cover  the  raw  connective  tissue  surface  of  it.  The  surfaces  exposed 
by  the  loosening  of  the  flaps  then  are  closed  by  means  of  fine  chromic 
catgut  sutures.  This  operation  has  been  permanently  successful. 
Operations  have  been  devised  whereby  a  loop  of  bowel  has  been 
brought  down  and  used  as  a  vagina.  The  ethical  basis  of  such  a 
procedure  is  at  least  questionable. 

2.  Abdominal  Hysterectomy  or  Removal  of  the  Ovaries. — If  the  arti- 
ficial vagina  persistently  contracts  and  cannot  be  kept  open  as  an  outlet 

1  Denver  Medical  Journal. 


CONGENITAL  GYNATRESIA  519 

for  monstriia!  fluid,  the  removal  oi'  the  uterus  would  be  justifiable  and 
prei'eral)le  to  reuioxal  of  the  oxaries. 

Operations  for  HaBmatocolpos. — If  the  obstruction  be  only  a  thin 
nieuii)rane,  it  may  be  incised  freely  and  the  fluid  let  out  as  in  ha^mato- 
mctra.  In  some  cases  there  is  absence  of  the  lower  and  distension  of 
the  u{)])er  part  of  the  vagina,  and  j)erhaps  also  of  the  uterus  and  Fallo- 
pian tubes.  Then  a  passage  must  be  made  carefully  to  the  point  of 
atresia  in  the  same  manner  as  for  opening  the  vagina  in  htematometra. 

An  operation  for  haMnatocolpos  or  htematometra  on  one  side  is  apt 
to  result  in  closure  of  the  opening  and  refilling  of  the  cavity.  For 
this  reason  it  is  important,  in  the  effort  to  secure  a  permanent  result, 
to  include  in  the  operation  the  free  division  of  the  septum  in  the  vagina 
and,  so  far  as  practicable,  in  the  uterus. 

In  hiematosalpinx  the  tubes  usually  will  empty  themselves  through 
the  uterus  when  that  cavity  is  drained,  and  do  not  therefore  have  to 
be  removed  or  otherwise  disturbed. 

Hfematocolpos  and  hfematometra  may  be  the  result  of  traumatic  as 
well  as  of  congenital  atresia ;  the  principles  of  treatment  are  then  the 
same  as  for  the  congenital  anomaly — that  is,  to  let  out  the  confined 
fluid  and  adopt  measures  to  keep  the  passages  open. 

The  formation  of  an  artificial  vagina  in  cases  of  vaginal  atresia  and 
rudimentary  uterus  has  in  rare  instances  been  followed  by  develop- 
ment of  the  uterus  and  normal  menstruation,  and  may  therefore  pos- 
sibly result  in  maternity.  The  probability  of  such  a  result,  however, 
is  so  slight  as  to  discourage  the  operation. 

It  occasionally  happens  that  complete  atresia  of  the  vagina  and 
absent  or  extremely  rudimentary  uterus  are  not  discovered  until  after 
marriage.  In  such  a  case  maternity  being  clearly  impossible,  the 
question  may  arise  whether  or  not  the  formation  of  an  artificial  vagina 
is  justifiable.  The  operation  follows  the  technique  already  laid  down 
for  the  formation  of  artificial  vaginas  in  cases  of  hsematometra.  Cases 
have  been  reported  in  w^hich  after  the  operation  marriage  was  happy,  the 
woman  even  recovering  from  a  tendency  to  melancholia,  and  experi- 
encing great  improvement  in  nervous  tone  and  general  strength.  The 
question  of  the  propriety  of  such  an  operation  may  be  relegated  to 
the  department  of  ethics  and  casuistry. 


PART   IV 
TRAUMATISMS 


CHAPTER  XXXV 
INJURIES  OF  THE  VULVA  AND  VAGINA 

NON-PUERPERAL   TRAUMATISMS 

The  genitals  are  protected  from  violence  by  their  situation  and 
relations  to  the  surrounding  parts,  and  therefore  are  little  exposed  to 
external  traumatism.  The  following  causes  of  non-puerperal  trauma- 
tism are  recognized:  1.  Falling  upon  a  sharp  object.  2.  Self-inflicted 
wounds  by  the  insane.  3.  Violent  coitus.  4.  A  blow  or  fall  which 
so  bruises  the  soft  parts  against  the  sharp  edges  of  the  descending 
ramus  of  the  pubes  or  the  ascending  ramus  of  the  ischium  as  to  make 
a  deep  cut.  The  cut  may  appear  at  the  surface  or  may  be  subcutaneous. 
TJie  symptoms  are  the  same  as  those  of  similar  injuries  elsewhere. 
Hemorrhage  from  the  abundant  vessels  about  the  vulva  is  usual  in 
wounds  of  that  region.  When  the  wound  is  external  the  bleeding  may 
be  alarming— even  fatal.  Great  subcutaneous  extravasation  of  blood 
may  occur  in  the  bruised  parts.  This  when  clotted  forms  a  pudendal 
JvFmatoma.  Superficial  incised  wounds  should  be  treated  by  suture. 
Bleeding-points  should  be  ligatured  with  fine  catgut.  Deep  punctured 
wounds  are  treated  best  by  compresses,  which  serve  for  dressings  and 
to  control  hemorrhage.  Small  haematomata  may  disappear  by  absorp- 
tion; if  too  large  for  absorption,  compresses  should  be  applied  for  four 
to  eight  days,  until  all  danger  of  hemorrhage  has  passed.  Then  a  free 
incision  should  be  made,  the  clot  turned  out,  the  cavity  packed  with 
aseptic  gauze  and  allowed  to  heal. 

PUERPERAL   LACERATIONS    OF   THE   PERINEUM 

Injuries  to  the  vaginal  outlet  and  pelvic  floor  usually  designated 
as  lacerations  of  the  perineum,  are  among  the  most  frequent  of  gyneco- 
logical lesions,  and  even  though  the  importance  of  these  injuries  some- 
times may  be  overestimated,  the  fact  is  undeniable  that  they  give  rise 
32  (521) 


522 


TRAUMATISMS 


to  many  serious  disorders  and  incon\eniences.  It  is  not  always  possible 
to  avoid  the  accident,  but  it  is  possible  to  recognize  it  when  it  occurs, 
and,  by  a  timely  operation,  prevent  evil  consequences.  A  laceration 
that  does  not  extend  into  and  destroy  the  functions  of  the  sphincter 
ani  muscle  is  incomplete.  The  laceration  is  complete  if  the  sphincter 
is  injured  sufficiently  to  impair  its  functions — i.  e.,  if  the  patient  has 
lost  power  to  retain  the  contents  of  the  bowel. 

FiGDBB    263 


Fresh  incomplete  tear  of  the  perineum.  Observe  the  rent  extending  outward  in  the  median  line 
toward  the  anus  and  inward  in  the  vaginal  sulci.  X,  X,  the  lowest  remains  of  the  hymen  on  each 
side — carunculae  myrtiformes. 


Pathological  Results 

The  results  of  incomplete  laceration  vary  with  the  extent  of  injury 
and  direction  of  the  tear.  The  extent  to  which  laceration  is  visible 
to  the  eye  is  not  a  safe  criterion,  for  the  chief  injury  may  be  in  the 
deeper  structures,  and  recognized  not  by  sight,  but  by  effects  which 
may  not  be  apparent  immediately  after  labor;  hence,  further  examina- 
tion is  a  necessary  part  of  the  efficient  management  of  the  puerperium. 
One  examination  should  be  made  immediately  after  labor,  to  recognize 
and  at  once  repair  such  injury  as  may  at  that  time  be  ^dsible;  another 
six  weeks  later,  to  recognize  and  repair  any  deeper  injuries  to  the  perineal 
fascia  or  muscles.  A  mere  rupture  in  the  perineal  body  where  certain 
muscles,  fasciee,  and  ligaments  of  the  pelvic  floor  converge  is  not  neces- 


INJURIES  OF   THE   Vl'LVA   AND   VAGINA 


523 


sarily  very  significant.  If,  however,  the  injury  involves  the  rending 
asunder  of  these  supports,  especially  the  le\iitor  aiii  muscle  and  the 
fascial  supi)orts;  if  they  are  so  di\ulsed  as  to  lose  their  sustaining 
power;  and,  above  all,  if  they  are  torn  of¥  from  their  pubic  attachments, 
the  lesion  becomes  more  serious. 

Complete  Laceration  through  the  sphincter  ani  muscle  which 
entirely  destroys  the  retentive  power  of  the  bowel  in  rare  instances 
occurs  subcutaneously  without  a  ^•isible  break  in  the  cutaneous  surfaces 
around  the  anus.  The  diagnosis  then  depends  upon  the  presence  of 
an  open,  relaxed  anus.  Relaxation  of  the  sphincter  and  incontinence 
of  the  bowel  may  occur  also  independently  of  laceration. 


Figure  264 


Fresh  complete  tear  of  the  perineum.  The  direction  of  rent  is  in  the  median  line.  The  rectovaginal 
wall  is  torn  apart  for  a  distance  of  about  one  inch.  A',  X,  lowest  carunculse  myrtiformes;  M,  M, 
broken  ends  of  the  sphincter  ani  muscle. 


Complete  laceration,  being  usually  in  the  median  line,  does  not  tear 
the  supports  of  the  pelvic  floor  so  much  as  the  incomplete.  ]\Ioreover, 
if  the  direction  of  the  tear,  whether  complete  or  incomplete,  be  in 
the  median  line,  the  muscles,  fasciae,  and  ligaments  are  not  so  seriously 


524 


TRAUMATISMS 


injured  as  they  would  be  if  the  tear  extended  transversely  across  the 
perineum,  especially  if  the  structures  were  torn  from  their  pubic 
attachments. 

Figures  271  and  272  show  the  child's  head  pressing  strongly  down- 
ward upon  the  levator  ani  muscles  and  the  rectovesical  fascia;  such 
pressure  gives  rise  to  great  sagging  of  the  pelvic  floor,  and  if  the  muscles 
and  fasciae  are  injured  extensively,  the  sagging,  unless  relieved  by  suit- 
able perineorrhaphy,  is  apt  to  be  permanent.     After  the  injury  the 


Figure  265 


Samej  as  Figure  264.     The  torn  parts  are  being  held  together  with  the  fingers,  so  that  X  coincides  with 
X  and  M  with  M.    This  adjustment  shows  what  parts  whould  be  united  in  repair  of  the  injury. 

whole  pelvic  floor,  including  the  rectum,  vagina,  urethra,  and  bladder, 
now  deprived  of  their  support,  tend  to  downward  and  backward  dis- 
placement toward  the  tip  of  the  coccyx.  The  rectum,  bladder,  and 
vagina  fall,  as  the  lower  jaw  would  fall  if  the  masseter  and  temporal 
muscles  were  cut,  or  as  a  tent  would  fall  if  the  guy  ropes  were  cut. 
The  backward  displacement  of  the  perineum  is  an  incident  and  an  index 
of  the  sagging.  In  very  many  of  the  worst  cases  the  injury  is  mainly 
intravaginal,  and  shows  little  or  no  external  evidence  of  laceration — 


/.V./f7»'//^N  OF   THE    177.r.l    .1A7)    VAGINA  525 


Relaxation  of  the  vaginal  outlet  consequent  upon  labor.    The  injury  is  confined  entirely  to  the 
interior,  no  cutaneous  rent.    The  perineum  is  extremely  thin. 


FiouRE  267 


Same  as  Figure  266.    The  index-finger  in  the  rectum  forces  the  rectocele  forward  through  the 

vulva. 


526 


TRAUMATISMS 


that  is,  the  cutaneous  structures  between  the  anus  and  the  posterior 
commissure  of  the  vulva  may  be  unbroken.  The  palpable  and  visible 
split  in  the  perineum  may  have  relatively  little  significance;  but  injury 
to  the  rectovesical  fascia  and  the  muscular  part  of  the  perineum  accounts 
for  frequent  impairment  of  function  in  the  organs  whose  cutlets  the 
muscles  control — that  is,  in  the  bladder,  urethra,  vagina,  and  rectum. 
Rectocele. — Figure  269  shows  the  direction  of  the  anus  to  be  at  an 
angle  to  that  of  the  rectum,  so  that  as  fecal  matter  comes  down  it  must, 
in  passing  from  the  rectum  out  through  the  anus,  turn  this  angle;  in 
so  doing  it  strikes  against  the  rectal  side  of  the  perineum,  and  thence 
is  deflected  through  the  anus.  If  the  injury  to  the  perineal  body  has 
made  it  thin,  weak,  or  relaxed,  or  otherwise  impaired  its  resisting  power, 
the  downward  force  of  the  feces,  instead  of  being  deflected  back:v\-ard 
and  outward,  will  cause  the  posterior  vaginal  wall  to  pouch  forward 
into  the  vagina,  Figure  270.  This  pouch  is  a  rectocele.  The  fecal  matter 
thus  arrested  requires,  with  the  enlarging  pouch,  more  and  more  force 
for  its  expulsion,  and  the  pouch  therefore  will  increase;  the  result  ^1 
be  rectal  and  anal  tenesmus,  irritation,  and  sometimes  anal  flssure  or 
fistula,  or  hemorrhoids. 


FiGUHE  268 

'W  // '   \\ w ' 

.Jk /&I— -l'^m:» 

A 

I 

^^k^'i 

M 

1 

\    ^ 

K"^-       M,JI1I1JJ^ 

If 

^^-                          ^Z^r^ 

1      1 

r 

^•^     y 

Uystocele  and  rectocele  consequent  on  injury  to  the  vaginal  outiei,. 

Cystocele. — The  perineum  having  been  impaired  by  rupture,  the 
vesicovaginal  septum,  which  normally  rests  upon  it,  tends  to  sag  and 
bulge  forward  into  the  vaginal  outlet  in  the  form  of  a  pouch.  This 
pouch  is  called  cystocele.  The  patient,  except  in  the  knee-chest  position, 
may  not  be  able  to  empty  the  bladder  completely.  Residual  urine 
may  accumulate  in  the  pouch,  decompose,  irritate  the  bladder,  and  may 


IXJIRIES  OF   THE   VrLVA    A\D   VM67AM  527 

FiQUBE  269 


Normal  relations  of  the  pelvic  organs  as  shown  in  section. 
Figure  270 


Cvstocele  and  rectocele  shown  in  section.    The  protruding  vaginal  wall  drags  the  uterus  down  after 
*"*    it     This  figure  shows  how  the  normal  relations  of  Figure  269  are  disturbed  by  laceration. 


528 


TRAUMATISMS 


set  up  cystitis  or  may  lead  to  the  formation  of  stone  in  the  bladder. 
In  order  to  expel  the  contents  of  the  bowel  the  woman  may  have  to 
hold  back  the  protruding  organs  with  the  hand. 

The  downward  force  of  straining  at  stool  to  empty  the  bladder  and 
rectum  increases  the  prolapse  of  the  vaginal  wall,  which,  being  attached 
to  the  uterus,  drags  that  viscus,  together  with  its  appendages  and  the 
rest  of  the  pelvic  floor,  to  a  lower  level,  and  thereby  gives  rise  by  traction 
to  various  displacements  of  the  reproductive  organs. 

A  wide  range  of  organic  and  mechanical  disorders  naturally  results 
from  cystocele  and  rectocele;  among  them  swelling  of  the  vaginal 
walls,  bearing-down  sensations,  a  feeling  that  the  "bottom  has  dropped 
out,"  difficulty  of  walking  and  standing,  backache,  constipation,  and 
many  nervous  disturbances. 

The  relaxed  or  lacerated  introitus  vaginae  permits  air  to  accumulate 
in  the  vagina,  and  at  intervals,  on  slight  change  of  position,  to  be 
expelled  suddenly  with  an  audible  sound,  "garrulity  of  the  vulva,"  w^hich 
simulates  the  sound  made  by  the  passage  of  flatus  from  the  bowel. 

Chronic  nervous  invalidism  is  the  possible  indirect  result  of  lacera- 
tion of  the  perineum.  This  subject  is  discussed  further  in  the  chapters 
on  Displacements. 


Figure  271 


Correct  incision  in  episiotomy.     Lines  B,  B,  show  incorrect  place  for  incision. 


Prophylaxis 

The  causes  of  laceration  of  the  perineum,  such  as  relative  dispropor- 
tion between  the  child  and  the  vaginal  outlet,  rapid  labor,  oedema  of 
the  vulva,  and  abnormal  rigidity  of  the  parts,  are  in  some  degree  pre- 
ventable by  retarding  labor  and  otherwise  giving  the  passages  time 


IXjrix'fl-S  OF   TNI':    VCLVA   AM)    VAdlXA  529 

for  dilatation  and  tlu-  ijrcsrntiiii;'  part  of  the  child  time  to  l)ec'ome 
molded  to  the  i)assa^a>s.  If  durin^^  lal)or  lacrratioii  appears  ciiiiiiciit, 
it  is  well  to  divide  the  vulvar  rinjj  by  an  incision  known  as  rjil.siolomy, 
and  thereby  substitute  a  clean  cut  in  another  direction  for  a  ra^'<;ed, 
lacerated  wound,  which  i)erhaps  might  involve  the  sphincter  muscle. 
The  usual  method  of  ei)isiotomy  is  to  make  a  transverse  incision  through 
the  middle  of  the  labium  majus  on  each  side.  B,B,  Figure  271.  The 
objections  to  these  injuries  are  that  the  rents  may  extend  still  farther 
in  the  lateral  direction,  as  the  head  passes,  and  that  an  additional  fresh 
tear  may  occur  at  the  posterior  commissure  of  the  vulva,  making  three 
wounds,  all  in  awkward  directions.  A  single  incision  in  the  direction 
shown  by  the  scissors,  Figure  271,  is  preferable,  for  any  further  tear 
will  be  to  one  side  of  the  sphincter  ani  muscle  instead  of  through  it. 
The  episiotomy  incision  after  delivery  is  closed  by  sutures  like  a  fresh 
laceration. 

Perineorrhaphy 

At  the  outset  we  may  take  exception  to  the  common  notion  that  the 
perineal  body  gives  support  to  the  pelvic  and  abdominal  organs  by 
N'irtue  of  being  under  them  and  in  the  ordinary  sense  holding  them  up 
as  foundations  hold  up  a  building.  The  muscles,  fascia,  and  other 
structures  of  the  perineal  region  surround,  bind  together,  hold  in  posi- 
tion, support,  and  maintain  by  their  mechanical  relations  the  terminal 
ends  of  the  rectum,  vagina,  and  urethra,  serve  to  control  them  in  the 
performance  of  their  functions,  and  as  active  integral  parts  of  the  pelvic 
floor,  contribute  to  the  support  of  the  pelvic  and  abdominal  organs  above. 
The  literature  on  the  subject  has  been  obscured  by  a  countless  variety 
of  operations  for  the  repair  of  the  perineum.  Every  medical  student 
is  appalled  by  their  number,  their  diversity,  and  their  complexity. 
It  is  hardly  possible,  however,  that  perineorrhaphy  should  furnish  an 
exception  to  the  great  general  principle  that  progress  in  any  direction 
is  characterized  always  by  simplicity.  The  object  of  perineorrhaphy  is 
to  replace  rather  than  to  enlarge  the  perineum.  ]\Iany  of  the  popular 
stereot\'ped  operations  which  enlarge  it  really  exaggerate  the  displace- 
ment because  they  do  not  reunite  properly  the  deep  muscular  and 
fascial  structures.  The  surgeon  often  is  asked  what  operation  he  per- 
forms on  the  perineum.  This  implies  that  there  is  some  fixed  operation 
which  is  universally  applicable.  It  would  be  no  less  absurd  to  ask 
what  plastic  operation  is  universally  applicable  to  lacerated  wounds 
of  the  face.  It  is  not  enough  for  an  operator  merely  to  get  union  at 
any  cost,  even  though  that  union  result  in  placing  a  solid  mass  of  flesh 
where  the  perineum  ought  to  be.  Great  harm  comes  if  the  parts 
brought  into  opposition  are  not  parts  which  belong  together. 

^Nlost  of  the  stereotyped  operations  are  prized  because  they  make 
the  "large,  solid,  perineal  body,"  but  such  a  perineum,  composed  of 
the  union  of  parts  which  do  not  belong  together  may  be  unfit  for  the 
performance  of  its  functions,  and  may  be  very  prone  to  subsequent 
rupture.     Even  a  torn  perineum  if  not  displaced  may  be  adequate. 


530 


TRAUMATISMS 


An  enormous  perineum,  if   displaced  toward  the  coccyx,  or  relaxed, 
may  require  operative  treatment.     One  should  apply  the  elementary 


Figure  272 


The  different  forms  ofiniu^^to^^^^^^^^^^ 
^^^urorthrtriaVgufar  %am^^^^^^^^  and  lateral  ruptures  of  the  sphincter  am 

muscle  around  the  anus  A. 

principle  that,  in  the  repair  of  a  wound,  the  essential  purpose  is  to  restore 
the  wounded  part  to  its  original  state.    He  should  nidividualize  each 


INJURIES  OF   THE    VULVA   AXD    VAGIXA  5;U 

case,  find  out  the  lines  of  tear,  their  direction,  their  ienjjth,  and  then 
put  the  fra<;uients  back  where  they  were  before. 

Before  goin^  on  to  the  technique  of  perineorrhaphy  it  will  be  profit- 
able to  consider  briefly  some  of  the  salient  factors  in  the  Anatomy  of 
the  Perineum  and  Perineal  Regions,  as  follows: 

The  perineum  is  the  converging  point  where  many  of  the  most 
important  parts  of  the  pelvic  floor  come  together;  these  parts  are: 
the  bulbocavernosus  muscle;  the  transversus  perinei  muscles,  super- 
ficial and  deep  fascia;  the  external  sphincter  ani  muscle;  the  internal 
sphincter  ani  muscle;  and  the  levator  ani  muscle.  The  muscles  are 
surrounded  and  bound  together  by  deep  and  superficial  fascia;  the  fascia 
in  some  places,  for  example  in  the  triangular  ligament,  is  quite  dense 
and  resisting.  All  the  perineal  muscles,  through  the  medium  of  tendon 
and  fascia,  are  directly  or  indirectly  strongly  connected  with  the  pubic 
bones.  The  muscles,  tendons,  and  fasciae  unite  in  the  perineum  to 
form  a  diaphragm  which  fills  the  pelvic  outlet.  Through  this  diaphragm 
pass  the  lower  portions  of  the  rectum,  anus,  vagina,  and  urethra. 
Vastly  predominating  in  importance  among  all  of  these  structures 
are  the  levator  ani  muscle  and  the  rectovesical  fascia,  and  especially  the 
triangular  ligament  which  lies  between  the  posterior  commissure  of  the 
vulva  and  anus,  and  which  is  the  common  meeting-point  of  muscular 
and  tendinous  structures.  Figure  272  shows  the  salient  points  of  the 
injury  as  it  pertains  to  the  structures  specially  mentioned  above. 

Direction  of  the  Tear 

One  of  the  most  important  and  most  serious  maxims  in  g\'necology 
should  be,  "Never  attempt  the  primary  or  secondary  closure  of  a  torn 
perineum  until  you  have  fuHy  and  clearly  demonstrated  and  appre- 
ciated the  direction  or  directions  and  extent  of  the  injury."^  Peri- 
neorrhaphy in  a  properly  broad  sense  comprises  not  merely  the  closure 
of  the  torn  perineum,  but  may  include  as  well  repair  of  injuries,  both 
deep  and  superficial,  of  other  structures  in  the  perineal  region. 

A  number  of  years  ago  I  was  called  to  make  immediate  repair  of  an 
incomplete  though  extensive  rupture  of  the  perineum,  ha\-ing  the 
belief,  then  commonly  held,  that  such  a  rupture  was  usually  a  splitting 
apart  of  the  perineal  body  into  two  lateral  fragments,  which  at  once 
retracted  to  the  corresponding  sides.  Accordingly,  sutures  were  intro- 
duced from  side  to  side  in  a  way  to  reunite  the  lateral  fragments  by  a 
line  of  union  which  should  extend  in  the  median  line  from  the  cutaneous 
to  the  vaginal  side  of  the  perineal  body.  The  amazing  result  of  this 
procedure  was  almost  complete  closure  of  the  vulva  so  that  the  index- 
finger  could  only  with  difficulty  be  introduced  into  the  vagina. 

The  absurdity  of  the  situation  was  more  apparent  than  the  explana- 
tion; evidently  the  lacerated  surfaces  had  not  been  brought  together 
properly — but  why?     Upon  removal  of  the  sutures  the  torn  surfaces 

1  E.  C.  Dudley.     Chicago  Clinical  Re\-iew,  April,  1S94.     The  accompanj-ing  description  of  perineor- 
rhaphy is  adapted  from  this  paper. 


532 


TRAUMATISMS 

Figure  273 


GROUP  I. 


GROUP  II. 


Diagram  1. 


Diagram  1. 


Diagram  2. 


Diagram  2. 


Diagram  3. 


Diagram  3. 


j^ 


cle 
4- 


Diagram  4. 


>. 


Diagram  4. 


INJURIES  OF   THE   VULVA   AND   VAGINA 


533 


GROUP  in. 


GROUP  IV. 


Diagram  1. 


Diagram  1. 


Diagram  2. 


Diagram  2. 


Diagram  3. 


Diagram  3. 


Diagram  4. 


-< d 


Diagram  4. 


534  TRAUMATISMS 

were  exposed  again.  A  study  of  the  injury  then  was  made  by  hook- 
ing together  opposite  sides  of  the  torn  surfaces  in  different  directions 
with  tenacula.  The  result  of  the  experimental  approximations  finally 
demonstrated  the  direction  and  character  of  the  rent. 

The  four  diagrams  under  Group  I.,  Figure  273,  explain  the  nature 
of  this  lesion  and  the  operation  of  repair.  Diagram  1  shows  the  margins 
of  the  wound  before  approximation.  Diagram  2  shows  the  approxima- 
tion, the  correctness  of  which  was  demonstrated  by  the  fact  that  all 
the  little  irregularities  accurately  fitted  into  one  another,  and  that  the 
integrity  of  the  vaginal  outlet  was  restored.  Diagram  3  shows  the 
sutures  in  position,  but  not  tied.  Diagram  4  shows  the  lines  of  union 
and  the  sutures  tied.  The  line  ahc,  Diagram  4,  represents  the  line  of 
tear  extending  from  side  to  side  across  the  vaginal  outlet  inside  the 
vulva;  the  point  h  is  situated  in  the  median  line;  points  a  and  c  represent 
the  extremities  of  the  vaginal  portion  of  the  rupture,  which  extended 
high  up  across  the  lateral  w^alls  of  the  vaginal  outlet  in  a  direction 
parallel  to  the  sides  of  the  vulva.  The  arrow-heads  show  the  directions 
in  which  the  fragments  retracted  after  the  rupture  until  the  exposed 
surfaces  assumed  the  shape  shown  in  Diagram  1. 

The  explanation  of  the  closure  of  the  vulva  by  the  first  procedure 
is  now  clear.  It  was  the  result  of  a  line  of  union  made  at  right  angles 
to  the  actual  line  of  tear — that  is,  the  vaginal  portion  of  the  rupture 
had  been  from  side  to  side,  or  in  the  transverse  direction;  it  was  closed 
as  if  it  had  been  a  longitudinal  instead  of  a  transverse  tear.  This  would 
close  the  vulva  to  a  point  as  high  as  the  injury  extended  on  either  side. 

In  order  to  explain  clearly  the  mechanism  of  the  rupture  shown 
in  Group  I.,  attention  is  called  to  another  and  tery  rare  form  of  rupture, 
known  as  comj^lete  central  riqjture  of  the  ijerineum — that  is,  a  rupture 
in  which  the  child  is  delivered  not  through  the  vulva,  but  through  a 
perforation  extending  from  the  vaginal  side  of  the  perineal  body, 
directly  through  the  perineal  body  to  its  cutaneous  side,  where  the 
birth  is  completed  between  the  vulva  and  the  anus.  This  complete, 
central  rupture  of  the  perineum  takes  place  in  the  transverse,  not 
in  the  longitudinal  direction.  The  transverse  direction  is  determined 
by  the  general  arrangement  of  the  muscles  and  fascia  surrounding 
the  vulva,  the  fibres  of  which  run  for  the  most  part  in  that  direction 
and  therefore  are  separated  more  readily  in  a  longitudinal  than  in  a 
transverse  direction. 

The  vast  majority  of  lacerations  begin  as  complete  central  rupture, 
following  the  direction  of  least  resistance — ^that  is,  transversely;  and 
continue  until  considerable  progress  has  been  made  in  the  separation 
of  the  perineal  structures  into  anterior  and  posterior  fragments  (line 
ahc,  Group  I.,  Diagram  4).  Then,  instead  of  continuing  to  complete 
central  rupture  and  perforation  of  the  perineal  body,  the  expulsive 
forces  are  opposed  more  and  more  by  the  strength  of  the  deeper  perineal 
structures,  the  direction  of  least  resistance  changes  to  the  longitudinal, 
with  a  corresponding  change  in  the  direction  of  the  rupture,  which  now 
takes  the  longitudinal  direction  shown  in  line  hf,  Diagram  4.    Notice 


ixjch'H'js  OF  THE  vulva  and  vagina  535 

the  direction  of  retraction  of  the  three  torn  fragments  as  shown  by  tlie 
arrow-heads  in  Diagram  4,  a  retraction  which  makes  the  irregular, 
torn  surface  of  Diagram  1.  The  exposed  surface  of  Diagram  1,  being 
partially  intravaginal,  often  recjuires  for  its  demonstration  the  sides 
of  the  vulva  to  be  separated,  or  the  perineum  to  be  lifted  forward  by 
the  index  and  middle  fingers  in  the  rectum. 

The  diagrams  in  (iroup  I.  represent  a  typical  perineal  laceration; 
the  other  three  groups  of  Figures  273  and  274  show  various  modifi- 
cations of  this  type.  In  each  of  these  four  groups  Diagram  1  represents 
the  exposed,  torn  surface  of  the  bruised  and  distorted  vaginal  outlet, 
which  approximates  in  each  instance  a  polygon  or  an  approximate 
circle  bounded  by  a  broken  outline.  It  is  an  interesting  fact  that  the 
description  of  any  one  of  these  torn  surfaces  will  without  change  apply 
perfectly  well  to  any  other — that  is,  when  the  labia  are  separated, 
the  outline  of  the  torn  surfaces  does  not  necessarily  give  a  definite 
idea  of  the  direction  of  the  rent.  For  example,  the  rent  may  be  in 
the  anteroposterior  direction,  and  the  two  lateral  fragments  may 
have  retracted  to  the  corresponding  sides,  making  the  outline  of  the 
laceration  as  shown  in  Group  IV.,  Diagram  1;  or  the  rent  may  have 
occurred  transversely,  and  the  torn  fragments  may  have  retracted, 
the  one  toward  the  vaginal  outlet  and  the  other  tow^ard  the  upper 
end  of  the  vagina,  leaving  a  similar  torn  surface,  the  outlines  of  which 
are  shown  in  Group  III.,  Diagram  1.  This  indefiniteness  in  shape  of 
outlines  in  the  exposed  surfaces  in  the  four  groups  is  not  only  conse- 
quent upon  the  retraction  of  the  torn  fragments,  but  it  is  also  caused 
by  the  loose,  flabby,  confused,  rasped  condition  of  the  vaginal  outlet — 
a  condition  common  at  the  end  of  parturition. 

Notice  Diagram  4  in  each  of  the  four  groups.  In  Group  I.  the  lines 
of  the  tear  correspond  approximately  to  the  shape  of  the  letter  Y. 
The  upper  part  of  the  letter  describes  the  transverse,  vaginal  portion 
of  the  tear;  the  staff  describes  the  longitudinal,  vulvovaginal  portion. 
We  really  have  three  distinct  lines  of  rupture:  one  shown  by  the  line  a  b, 
another  by  the  line  b  c,  and  the  third  by  the  line  bf.  Lines  b  c  and  bf 
of  this  figure  describe  the  rupture  of  Group  II.  In  Group  II.  the  vaginal 
portion  of  the  rupture  runs  diagonally  to  the  patient's  left.  A  precisely 
similar  condition  would  be  that  in  which  the  vaginal  portion  of  the 
rupture  runs  diagonally  to  the  patient's  right;  so  that  we  may  have, 
in  addition  to  Group  II.,  in  which  the  laceration  is  left-lateral,  a  pre- 
cisely similar  injury  in  which  it  would  be  right-lateral.  Lines  a  b  and 
be,  Group  I.,  describe  the  rupture  of  Group  III.;  line  bf,  Group  I., 
describes  the  rupture  of  Group  IV. 

One  may  find,  therefore,  in  the  study  of  individual  cases,  by  approxi- 
mating the  margins  of  the  tear  with  tenacula,  that  the  injury  may 
correspond  to  any  one  or  all  of  the  lines  of  Group  I.,  or  to  any  combina- 
tion of  them.  It  may  further  show  any  variation  in  the  length  or 
regularity  of  these  lines.  It  is  a  cardinal  principle  that,  be  these  lines 
ever  so  variable  in  length  and  regularity,  they  can  always  be  referred 
to  the  typical  lines  shown  in  Diagram  4,  Group  I. 


536  TRAUMATISMS 

The  letters  which  have  been  used  to  designate  the  different  points 
in  each  cut  have,  for  purposes  of  convenience,  been  made  to  corre- 
spond one  for  all.  For  example,  point  h  in  Diagram  3,  Group  III., 
occupies  the  same  relative  position  as  point  h  in  any  other  figure. 

It  is  important  to  appreciate  the  mechanism  of  the  injury  as  indi- 
cated by  the  arrow-heads  in  Diagram  4  of  each  group.  They  show 
the  direction  in  which  the  torn  fragments  retract  to  make  the  broken 
outline  indicated  by  Diagram  1  of  each  group. 

Description  of  Perineorrhaphy  for  Complete  Rupture 

Suture  Material  may  be  chromic  catgut  or  silkworm-gut,  or  both;  if 
both  are  used,  catgut  may  be  employed  for  the  intravaginal,  and  silk- 
worm-gut for  the  extravaginal  cutaneous  portion  of  the  repair.  The 
reason  for  the  distinction  is  that  stitch-hole  suppuration  is  more  apt 
to  occur  in  the  cutaneous  portion  and  silkworm-gut  is  safer  against 
such  suppuration  than  catgut.  Experience  has  shown  that  a  good 
quality  of  thoroughly  sterilized  thirty-day  chromic  catgut,  No.  1 
size,  is  permissible  for  the  entire  operation,  pro\dded  all  details  of 
technique,  such  as  accurate  apposition  and  accurate  introduction 
of  catgut  are  observed.  Notwithstanding  this  favorable  experience 
with  catgut  it  must  be  admitted  that  for  the  external  sutures  at  least 
silkworm-gut  is  more  dependable  than  catgut.  Above  all  it  is  important 
that  the  sutures  be  not  tied  tightly.  The  tension  should  be  only  suffi- 
cient to  approximate  the  parts  rather  loosely.  Tight  drawing  of  sutures 
strangulates  the  parts,  reduces  their  resistance  to  infection,  causes 
swelling,  increases  wound  secretions,  and  may  result  in  the  sutures 
cutting  out  and  giving  rise  to  suppuration. 

^Yhen  the  torn  surfaces  have  healed  over  and  cicatrized,  after  an 
unsuccessful  primary  operation  or  after  no  operation  at  all,  correct 
denudation  is  essential,  and  is  made  possible  only  by  studying  the  lines 
of  the  original  tear  by  means  of  a  tenaculum  in  each  hand  and  ha\ang 
in  mind  the  remains  of  the  hymen  and  the  crest  of  the  rectocele  as 
follows : 

When  labor  has  not  resulted  in  laceration,  the  vaginal  outlet  will 
be  surrounded  by  the  remains  of  the  hymen,  which  mark  off  the 
vulva  from  the  vagina — that  is,  by  the  carunculae  m^Ttiformes.  These 
consist  of  numerous  small  protuberances  situated  near  together  and 
surrounding  the  vulva,  as  it  were,  like  a  string  of  beads.  They  are 
sometimes  so  close  together  and  pronounced  as  almost  to  constitute 
an  annular  hymen. 

This  circular  line  of  carunculse  mATtiformes,  in  case  of  laceration, 
is  broken  at  a  point  near  the  posterior  commissure  of  the  vulva,  and 
when  the  break  occurs  the  lowest  caruncle  on  either  side  of  the  rupture 
is  retracted  to  the  corresponding  side  of  the  vulvar  outlet.  In  a  typical 
laceration,  the  two  lowest  caruncles  will  correspond  to  points  d  and  e 
in  the  diagram  of  Group  I.,  Figure  273  and  274.  Their  location  is  indi- 
cated also  in  the  corresponding  points  of  Groups  II.  and  IV.,  Figures 


/.\Vr/,7A'N  OF   THE   VULVA   AMD   VAdlNA 


ryM 


27.'i  and  2/1.     Figures  275  to  288  show  the  caruncles  as  tlie>'  appear 
in  the  \ari()us  staji'es  of  the  operation.    Tlie  two  lowest  earuncles,  on 


Figure  27.5. — T,\)i!ial  inromplete  laceration  of  the  perineum.  The  tenacukim  hooked  into  the 
orest  of  the  rectocele  at  point  6  draws  it  slightly  forward.  The  other  two  tenarula  are  hooked  into 
the  lowest  remains  of  the  hymen,  points  V/  and  e  (carunculae  myrtiformes).  The  three  tenaeula  if 
appro.ximated  would  bring  into  coincidence  points  b,  d,  and  e,  and  would  show  what  surfa<'es  should 
be  united. 

Figure  276. — Same  as  275.  Tenaculum  at  d  removed  and  placed  at  /.  Tenaeula  &,  e,  and  /  make 
traction  so  as  to  render  tense,  lift  up  and  expose  for  denudation  the  torn  sulcus  of  the  left  side.  The 
ridges  formed  by  the  structures  drawn  taut  indicate  the  outline  of  the  surface  to  be  denuded. 


Figure  278 


Figure  277. — Denudation,  with  Emmet's  slightly  curved  scissors,  of  the  surface  exposed  in  Figure 
276.  X  strip  is  denuded  all  around  the  surface,  leaving  an  undenuded  island  in  the  centre,  which 
retracts  to  small  size. 

Figure  27S. — The  island  of  undenuded  surface  left  after  denudation  of  the  strip  around  the  sur- 
face, being  hooked  up  by  a  tenaculum  and  removed  with  scissors.  The  denudation  shown  on  the  right 
side  of  Figures  277  and  27S  is  to  be  carried  out  also  in  a  similar  manner  on  the  left.  The  next  figure 
shows  denudation  complete. 

33 


538 


TRAUMATISMS. 


Figure  279 


Figure  280 


Figure  279. — This  shows  the  surfaces  denuded  but  not  yet  ready  for  sutures.  Some  operators 
prefer  to  expose  the  surface  on  both  sides  for  denudation  in  the  manner  in  which  they  are  exposed  in 
this  illustration.  In  the  use  of  either  method  it  is  desirable  to  denude  on  each  side  somewhat  farther 
back  into  the  sulcus  than  is  here  shown. 

Figure  280. — The  undenuded  triangular  tongue-shaped  surface  which  in  extreme  cases  of  descent 
of  the  posterior  vagina  covers  the  crest  of  the  rectocele  is  here  shov.'n  stripped  off  from  its  attachments, 
that  is.  this  undenuded  part  of  the  vaginal  plate  of  the  rectovaginal  septum  is  stripped  off  from  the 
rectal  plate  and  lifted  up.  The  stripping-off  process  is  well  accomplished  bj'  seizing  the  margins  of 
this  undenuded  surface  -n-ith  forceps  and  detaching  it  from  the  rectal  plate  by  means  of  sponge 
pressure,  that  is.  rather  than  dissecting  it  off.  The  loose  cellular  tissue  between  the  rectal  and  vaginal 
plates  is  easily  divided  in  this  way.  Observe  the  incision  on  one  side  of  the  denuded  surface  through 
which  the  levator  ani  muscle  show-s.  A  similar  incision  is  being  made  on  the  other  side.  This  repre- 
sentation of  the  levator  ani  muscle  is  somewhat  diagrammatic,  that  is,  it  is  seldom  demonstrated  in 
the  actual  operation  as  clearly  as  the  illustration  indicates. 


Figure  281 


Figure 

282 

i 

^<l  . 

)l 

// 

1 

l\ 

If 

x\ 

} 

] 

1 

f 

/ 

Figure  281. — Number  1  chromic  catgut  sutures  are  here  shown  in  place  but  not  tied.  The 
purpose  of  these  sutures  is  to  bring  together  the  broken  fragments  of  the  levator  ani  muscle  and  the 
triangular  ligament,  and  other  parts  of  the  rectovesical  fascia. 

Figure  282. — Same  as  Figure  281.  The  levator  ani  muscle  and  other  deep  perineal  structures 
united  by  Number  1  chromic  catgut  sutures  preparatory  to  the  next  step  of  closing  the  superficial 
portions  of  the  perineum. 


IXJURIES  OF  THE   VULVA   AND   VACIXA  539 

Figure  284 


FlGlKK     L'S3 


Figure  2S3.— All  the  sutures  in  the  two  lateral  sulci  have  been  introdiiced  and  tied.  While  the 
assistant  is  making  strong  traction  upward,  the  crown  suture,  which  brings  together  the  two  carunculee 
m.vrtiformes  and  the  posterior  vaginal  wall,  is  being  tied.  This  completes  the  intravaginal  part  of  the 
operation. 

Figure  284. — The  suture.s  which  have  completed  the  intravaginal  part  of  the  operation  are  being 
drawn  strongly  upward  by  the  assistant,  so  as  to  lift  the  perineum  toward  the  pubes  while  the  first 
suture  of  the  external  part  of  the  operation  is  being  passed.  Obsen-e  the  action  of  the  finger  in  making 
counterpressure  as  the  needle  is  passed  through. 


Figure  2S.5 


Figure  2S6 


^:j/ 

.!/ 

\ 

"H--^ 

^ 

in 

3^ 

/ 

-*  s 

Y 

X 

i 

/ 

\ 

Figure  28r>. — .\11  the  sutures  intended  for  closure  of  the  perineum  ha^-ing  been  tied  are  now  tempo- 
rarily held  down  and  away  from  the  vulva,  as  shown  in  this  Figure.  This  is  to  facilitate  the  passage 
of  a  special  suture  just  back  of  the  crown  suture.  As  soon  as  this  special  suture  has  been  passed,  and 
before  it  is  tied,  the  bundle  of  sutures  is  returned  to  its  former  position,  as  shown  in  the  next  Figure. 
The  purpose  of  the  suture  now  being  passed  will  become  apparent  in  the  next  two  Figures. 

Figure  286. — The  special  suture  introduced  in  the  last  Figure  is  now  being  tied:  its  purpose  is 
to  secure  in  a  bundle  the  other  sutures  and  hold  them  down  against  the  posterior  wall  of  the  introitus 
vaginae.  The  next  Figure  will  show  all  the  sutures  turned  into  the  vagina.  The  special  suture  retains 
them  there.    The  free  ends  of  this  retention  suture  are  carried  with  the  others  into  the  vagina. 


540 


TRAUMATISMS 


being  approximated  by  tenacula  show  the  surfaces  to  be  united  in  the 
external  parts  of  the  rupture. 

Having  located  the  two  lowest  caruncles  find  some  point  near  th? 
centre  of  the  upper  fragment,  point  b,  Figure  275  (if  a  rectocele  has 
formed,  this  will  be  its  crest),  and  while  the  two  caruncles  d  and  e  are 
being  held  together,  let  point  b  be  drawn  into  coincidence  with  points 
d  and  e.  Then  will  the  points  b,  d,  and  e  come  together  and  form  one 
and  the  same  point.  The  coincidence  of  these  three  points  will  show 
what  surfaces  should  be  denuded  and  united  upon  themselves. 

The  technique  of  this  operation  is  further  described  under  Figures 
275  to  288. 


Figure  287 


Figure  288 


Figure  287. — This  sectional  view  of  the  sutures  in  position  and  tied  completes  the  illustrations 
cf  the  operation  for  incomplete  laceration  of  the  perineum.  The  entire  bundle  of  sutures  is  shown 
turned  into  the  vagina,  where  they  cannot  irritate  the  wound.  This  arrangement  permits  adequate 
dressings  over  the  external  parts  of  the  wound,  and  does  away  with  the  irritating  and  distressing  ends 
of  the  sutures  which  commonly  are  left  in  contact  with  the  external  surfaces,  and  w;hich  always  con- 
tribute enormouslv  to  the  discomfort  and  pain  of  convalescence.  A  section  of  a  Sims  speculum  is 
shown  here.  The  instrument  introduced  in  this  way — i.  e.,  hooked  under  the  pubes,  with  the  patient 
in  the  dorsal  position — facilitates  the  turning  in  of  the  sutures  at  the  close  of  the  operation,  and  may 
be  again  used  in  their  removal. 

Figure  288. — In  the  removal  of  a  suture  a  single  free  end  is  caught  with  the  forceps  and  the  loop 
cut  with  the  scissors  at  one  side  of  the  knot.  The  external  sutures  should  be  removed  at  the  end  of 
two  weeks,  and  the  intravaginal  sutures  if  of  silkworm  gut  in  about  twenty  days.  The  vagina  is  ex- 
posed here  by  a  Sims  speculum  hooked  under  the  pubes  and  the  crown  suture  is  being  removed.  The 
remaining  sutures  are  drawn  out  of  the  vagina  and  removed  one  by  one.  Observe  the  tenaculum  point 
on  the  fine  blade  of  the  scissors,  which  holds  up  the  loop  and  guards  against  the  cutting  off  of  the  knot 
which  might  cause  the  loop  to  retract  out  of  reach.  A  pledget  of  cotton  saturated  with  a  6  per  cent, 
solution  of  cocaine  retained  in  the  outlet  of  the  vagina  for  ten  minutes  renders  removal  of  the  sutures 
less  painful.  //  chromic  catgut  is  used  instead  of  silkworm-gut,  the  sutures  may  he  cut  short  and,  being  of 
absorbable  material,  will  be  absorbed,  and  therefore  do  not  have  to  be  removed  as  described  under  Figures  28-5 
and  286. 


After-treatment. — The  patient  is  not  catheterized  unless  unable  to 
pass  urine.  Normal  urine  in  contact  with  the  wound  is  harmless. 
Uncleanly  catheterization  is  a  recognized  cause  of  cystitis.  A  much  more 
insidious  and  less  obvious  cause  is  failure  of  the  'patient  completely  ^  to 
empty  the  bladder  on  urination  and  the  consequent  retention  of  decomposing 
residual  urine  which  may  set  up  cystitis.  Such  retention  of  urine  is  apt 
to  result  from  the  .use  of  morphine,  which  is  usually  given  to  relieve  pain. 


IXJlh'lES   OF   THE    VVLVA    AM)    VAdlXA  541 

///  ,s'//f7/  fv/.sT.v  llic  hldddir  .should  he  com iildchj  ciiipllcd  al  least  oiirr  (t  dai/ 
by  cat  hctcnzdt  toil  a  ml  at  the  .s-aiiic  time  jlushcd  oiil  irllli  horic  acid  sol  nl  ion. 
See  Prophylaxis  of  Cystitis  in  the  chapter  on  Cystitis.  Tiie  bowels 
should  he  kept  regular  by  enema  or  by  cathartics  if  necessary,  the  same 
as  if  no  ()])erati()n  had  been  performed.  I)nrin<;-  conNalescence  the 
patient  may  lie  in  any  desired  position.  When  the  [)atient  is  on  the 
back  the  legs  and  thighs  may  be  more  comfortable  if  supported  on  a 
roll  made  of  a  blanket,  comforter,  or  pillow.  A  sterile  douche  one- 
fourth  of  one  per  cent,  lysol  should  be  given  every  twelve  haurs,  and 
the  external  parts  showered  off  after  urination  or  defecation.  The 
wound  is  dressed  antiseptically  with  a  pad  of  gauze  and  cotton  held 
in  place  over  the  vulva  by  a  T-bandage. 

If  secondary  hemorrhage  occur,  the  indication  is  for  anjiesthesia  and 
prompt  ligature  of  the  bleeding-point.  For  this  purpose  the  parts  may 
be  exposed  by  a  speculum,  hooked  under  the  pubes. 

The  external  sutures  should  be  removed  in  twelve  to  fourteen  days. 
The  vaginal  sutures  if  of  catgut  will  be  absorbed;  if  of  silkworm-gut, 
they  should  be  removed  in  about  eighteen  days.  The  removal  of  the 
latter  is  facilitated  by  the  use  of  Sims'  speculum  reversed — that  is, 
hooked  under  the  pubes,  the  patient  being  on  the  back. 


DESCRIPTION  OF  PERINEORRHAPHY  FOR  COMPLETE  RUPTURE 

Perineorrhaphy  involving  the  sphincter  ani  muscle  differs  in  some 
details  from  the  operation  just  described;  first,  in  the  preparatory 
treatment;  second,  in  the  denudation;  third,  in  the  passage  of  the 
sutures;  fourth,  in  the  after-treatment. 

Preparatory  Treatment 

The  chances  for  union  of  the  wound  are  increased  by  limiting  the 
amount  of  feces  which  may  pass  over  it  during  the  first  days  following 
the  operation;  hence  the  bowels  should  be  as  nearly  empty  and  aseptic 
as  practicable.  With  this  object  they  should  be  treated  as  in  the 
preparation  for  major  operations,  Chapters  V.  and  VI. 

Denudation 

Figure  290  shows  the  rent  extending  up  into  the  rectovaginal  septum. 
At  points  M  and  M  are  two  pits  or  depressions  caused  by  retraction 
of  the  torn  ends  of  the  sphincter  ani  muscle.  The  principal  object  of 
the  operation  is  the  union  of  these  ends  and  the  consequent  restora- 
tion of  sphincteric  function.  The  denudation,  therefore,  must  include 
the  pits  or  depressions.  They  may  be  seen,  though  not  always  without 
careful  search,  at  either  side  of  the  anus.  The  denudation  starts  just 
below  the  pit  on  the  patient's  left,  and  is  carried  around  on  the  margin 
of  the  torn  rectovaginal  septum  to  include  the  opposite  pit. 


542 


TRAUMATISMS 


A  common  fault  in  denudation  is  not  to  include  these  torn  ends  of 
the  sphincter.  Observe  carefully  that  they  are  situated  well  down  on 
a  level  with  the  posterior  margin  of  the  anus.  Failure  to  carry  the 
denudation  well  belovr  them  clearly  would  defeat  the  object  of  suture. 

Before  ixissing  the  sutures  which  are  to  reunite  the  sphincter  muscle, 
the  torn  ends  should  he  dissected  out  mid  exposed  for  suture  as  shown 
in  Figures  291  and  292.  The  remaining  portion  of  the  denudation  is 
carried  out  the  same  as  for  incomplete  laceration. 


Figure  289 


Figure  290 


FAULTY 
M  ETHOD 
OF    SUTURE 


Figure  289. — An  unsuccessful  result  after  a  faulty  operation  for  complete  perineorrhaphy.  Such 
failures  are  due  commonly  to  the  fault  of  the  operator  in  not  bringing  together  the  torn  ends  of  the 
sphincter  ani  muscle.  Obsem^e  the  radiating  folds  below  the  anus.  After  a  successful  operation  these 
folds  should  radiate  in  all  directions.  After  an  unsuccessful  operation  they  only  radiate  downward, 
as  shown  in  the  Figure.  The  retracted  ends  of  the  torn  muscle  are  shown  by  the  small  pits  marked 
M,  M,  Figures  289  to  290.  The  lower  sutures  should  always  be  passed  through  the  ends  of  the  muscle, 
as  shown  in  Figure  291. 

Figure  290. — Faulty  method  of  passing  the  anal  sutures.  Interrupted  sutures  placed  in  this 
manner  and  tied  on  the  bowel  side  of  the  wound  are  open  to  the  following  objections;  1.  They  make 
a  long  Une  of  union  which  is  exposed  to  the  hostile  en\aronment  of  the  bowel.  2.  The  knots  and  free 
ends  of  the  suture  in  the  bowel  may  take  up  septic  secretions  and  carry  them  by  capillary  attraction 
to  the  deeper  parts  of  the  wound,  and  in  this  way  cause  infection  and  failure  of  union.  3.  A  long  line 
of  union  is  difficult  to  protect  against  infection. 


Introduction  of  Sutures 


The  sutures  should  be  of  silkworm-gut.  The  first  two  or  three 
should  be  introduced  to  the  left  of  the  anus,  should  pass  somewhat 
deeply  under  the  left  pit,  should  sweep  around  under  the  border  of  the 
torn  septum,  and  pass  under  the  opposite  pit  and  emerge  to  the  right 
of  the  anus.  Figure  292  shows  the  ends  of  the  sphincter  to  be  united 
by  three  sutures.  These  sutures  having  been  tied  the  problem^  will 
he  simplified  to  that  of  an  incomplete  operation,  and  the  remaining 
sutures  will  be  placed  as  already  described  for  closure  of  an  incomplete 
laceration. 


INJURIES  OF  THE   VULVA   AND   VAGINA 


543 


Complicated  Operations 

In  some  cases  of  complete  laceration  of  tlio  perineum,  and  more 
rarely  in  iiu'omi)lete  laceration,  so  much  tissue  lias  been  lost  from 
sloughing  or  from  repeated  denudation  in  former  unsuccessful  attempts 
at  closure,  that  the  denuded  surfaces  cannot  be  approximated  by 
sutures.'  In  such  cases  recourse  mav  be  had  to  the  device  shown  in 
Plate  XIII.,  Chapter  XXII. 


Figure  291 


Figure  292 


Figure  291. — Complete  laceration  of  the  perineum  involving  the  sphincter  muscle.  Denudation 
complete  ready  for  suture.  Recur  to  the  pits  which  mark  the  retracted  torn  ends  of  the  sphincter 
muscle,  M,  M,  in  Figure  290.  On  the  right  the  torn  end  of  the  muscle  M  is  expo.sed,  having  been  dis- 
sected out  through  an  incision,  on  the  left  an  incision  with  scissors  is  being  made  for  the  purpose  of 
exposing  the  end  of  the  muscle  on  that  side. 

Figure  292. — The  torn  ends  of  the  sphincter  muscle  exposed  and  silkworm-gut  sutures  in  place  but 
not  tied,  for  restoration  of  the  anal  portion  of  the  tear  including  reunion  of  the  sphincter.  An  addi- 
tional No.  0  chromic  catgut  suture  is  sometimes  introduced  to  hold  the  fragments  of  the  sphincter 
together.  This  is  the  purse-string  method  of  suture.  This  draws  the  wound  into  a  small  compass;  it  leaves 
no  part  of  a  suture  in  the  bowel  to  absorb  and  carry  septic  secretions;  the  inner  angle  of  the  anal  portion  of 
the  wound  is  drawn  down  to  the  margin  of  the  anus,  where  it  is  less  liable  to  infection  than  if  the  wound 
were  longer  and  exposed  to  the  interior  of  the  bowel.  Experience  has  shown  that  this  method  of  suture  is 
immeasurably  more  successful  in  securing  primary  union  than  that  shown  in  Figure  290. 

After-treatment  of  Perineorrhaphy  for  Complete  Rupture 

In  addition  to  the  general  directions  for  after-treatment  of  incomplete 
perineorrhaphy  already  noted,  the  following  points  should  be  observed: 
A  full  cathartic  of  castor  oil  or  compound  licorice  powder  should 
be  given  on  the  third  day,  and  repeated,  if  necessary,  to  secure  free 
catharsis.  Excessive  catharsis,  producing  frequently  repeated  liquid 
stools,  might  set  up  irritation  of  the  anus  sufficient  to  prevent  healing 
and  therefore  should  be  arrested  by  the  use  of  a  teaspoonful  of  paregoric 
every  time  the  bowels  act  until  stools  are  less  frequent.    After  the  first 


1  The  author  published  this  method  in  Surgery,  Gynecology,  and  Obstetrics,  June,  1906.     It  gave 
a  good  result  in  one  case  after  seven  unsuccessful  attempts  at  closure  by  the  ordinarj'  method. 


544 


TRAUMATISMS 


Figure  293 


Figure  294 


Figure  293. — Represents  repair  of  a  complete  perineal  laceration  extending  into  the  lateral  sulci 
of  the  vagina.  The  three  sutures  which  reunite  the  ends  of  the  sphincter  ani  muscle  are  tied  and  held 
to  one  side  by  forceps.  Vaginal  sulci  closed  with  stitches  on  each  side,  which  are  tied  and  held  up 
by  the  assistant.  The  needle  is  being  introduced  for  the  passage  of  the  crown  stitch  which  unites  the 
lowest  caruncles.  There  is  usually  no  rectocele  in  complete  laceration.  The  remaining  sutures  to 
be  passed  will  close  the  external  part  of  the  wound.  Observe  that  the  folds  about  the  restored  anus 
radiate  in  all  directions  instead  of  downward,  as  in  Figure  289.  This  all  around  radiation  is  a  reliable 
indication  of  the  adequacy  of  the  anal  sutures. 

Figure  294. — Subcutaneous  rupture  of  the  sphincter  ani  muscle:  The  torn  ends  of  the  muscle  have 
been  exposed  by  an  incision  through  the  skin  and  subcutaneous  structures. 


Figure  295 


Figure  296 


Figure  295.— Subcutaneous  rupture  of  the  sphincter  ani  muscle:  The  torn  ends  of  the  muscle  are 
being  united  by  means  of  No.  0  chromic  catgut  sutures.  I  have  had  some  failures  from  the  use 
of  catgut  and  now,  therefore,  supplement  it  with  silkworm-gut,  passing  it  m  and  out  through  the 
skin  in  such  a  way  as  to  fortify  the  catgut.  .  ,         ^    .  j        u     ^         „„ 

Figure  2m —Subcutayieous  rupture  of  the  sphincter  am  muscle:  Cutaneous  and  subcutaneous 
structures  over  the  repaired  sphincter  being  united  by  silkworm-gut  sutures.  Silkworm-gut  is  prefer- 
able;   catgut  is  apt  to  be  absorbed  too  early. 


/.VjrA'/A'N   OF    THE    VI  LVA    AXD    VAGIXA  545 

in()\x'nuMit  of  the  howt'ls  the  stools  should  he  kept  soft.  This  may 
recjuire  a  eathartie  at  interxals  of  not  more  than  two  days.  During 
the  first  week,  whene\er  the  bowels  are  al)out  to  move,  it  is  well  to  give 
a  rectal  enema  of  eight  ounces  of  olive  oil.  In  giving  the  enema  the 
syringe-tip  should  he  passed  carefully  along  the  posterior  wall  of  the 
anus  away  from  the  anal  sutures.  Carelessness  at  this  point  may  break 
open  the  newly  united  surfaces  and  destroy  the  result.  An  inexperi- 
enced nurse  should  not  be  permitted  to  give  the  enema.  A  milk  diet, 
which  is  apt  to  form  masses  of  caseine  in  the  rectum,  and  therefore  on 
defecation  endanger  the  recently  united  sphincter,  should  be  avoided. 

If  there  is  no  suppuration,  the  sutures  should  not  be  removed  until 
about  the  fourteenth  day.  In  other  respects  the  after-treatment  is 
the  same  as  for  incomplete  laceration. 

//  there  is  retention  of  urine  and  the  catheter  is  required,  one  may  avoid 
the  cystitis  which  sometimes  foUoics  catheterization  by  throwing  into  the 
bladder  two  drachms  of  a  10  per  cent,  solution  of  argyrol,  and  leaving  it 
there  after  each  catheterization.  As  stated  in  a  previous  paragraph  it  is 
essential  to  avoid  the  presence  in  the  bladder  of  residual  urine. 

In  the  immediate  operation  of  perineorrhaphy,  that  is,  perineorrhaphy 
of  the  recently  torn  surfaces,  denudation,  except  possibly  the  trimming 
off  of  any  ragged  edges  of  the  wound,  is  unnecessary.  In  other  respects 
the  operation  is  substantially  the  same  as  the  secondary  operation 
already  described  in  the  preceding  paragraphs  and  illustrations. 

Subcutaneous,  Rupture  of  the  Sphincter  Ani  Muscle. — Sometimes,  in 
consequence  of  labor,  the  sphincter  ani  muscle  is  subcutaneously  rup- 
tured without  any  considerable  separation  of  the  overhang  cutaneous 
structures.  The  same  accident  to  the  sphincter  not  infrequently 
results  from  forcible  dilatation  of  it  in  surgical  operations.  The  repair 
of  this  injury  is  set  forth  in  Figures  294,  295,  and  296. 


CHAPTER   XXXVI 

PUERPERAL  LACERATION  OF  THE  CERVIX  UTERI 

The  credit  of  having  established  the  pathological  significance  and 
surgical  treatment  of  laceration  of  the  cervix  uteri  belongs  to  Emmet. 
His  three  original  communications^  not  only  contained  the  first  practical 
information  on  the  subject,  but,  what  is  more  remarkable  when  we 
consider  the  great  frequency  and  the  far-reaching  pathological  results 
of  the  lesion,  the  information  which  they  contained  was  at  once  so 
complete,  so  accurate,  and  so  adequate  that  little  if  anything  of  impor- 
tance has  been  added.  Vague  allusions  to  the  subject  had  appeared 
from  time  to  time  before  the  publication  of  Emmet's  papers,  but  only 
to  record  the  fact  that  such  an  injury  could  result  from  parturition. 
They  contained  little  account  of  its  pathological  significance  and  none 
of  its  surgical  treatment. 

Causes  of  Laceration  of  the  Cervix  Uteri 

The  causes  of  laceration  of  the  cervix  uteri  are: 

Relative  disproportion  in  size  between  the  child  and  the  cervix. 

Rigidity  of  the  cervix. 

Rapid  labor. 

Any  disease   of   the   cervix    which    causes    friability    or   impairs 

elasticity. 
Instrumentation. 

Manipulation,  such  as  manual  dilatation  of  the  cervix  to  hasten 
labor. 
The  cervix  is  not  fully  prepared  for  dilatation  and  the  transmis- 
sion of  the  child  until  the  end  of  the  normal  period  of  gestation;  hence 
the  greater  liability  to  injury  in  premature  and  immature  labor.  Abor- 
tion in  the  earlier  months  of  pregnancy  is  not  a  frequent  cause  of 
laceration,  except  as  it  may  result  from  forcible  dilatation.  A  greatly 
prolonged  labor  may,  by  continued  pressure,  induce  nutritive  changes, 
and  thereby  decrease  the  elasticity  and  increase  the  liability  to  rupture. 
The  condition  is  an  approach  to  pressure-necrosis. 

Pathological  Anatomy  and  Results  of  Laceration  of  the 
Cervix  Uteri 

At  the  outset,  let  the  important  fact  be  kept  clearly  in  mind  that 
the    injury  is    usually    more    extensive   in    the    surrounding    vaginal 

1  "Surgery  of  the  Cervix  Uteri."  American  Journal  of  Obstetrics,  February,  1869.  "Laceration 
of  the  Cervix  Uteri  as  a  Frequent  and  Unrecognized  Cause  of  Disease."  Ibid.,  November,  1874. 
"The  Proper  Treatment  of  Lacerations  of  the  Cervix  Uteri."    American  Practitioner,  January,  1877. 

(  546  ) 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI 


547 


structiirt's  than  in  the  ccnix  proper.  This  is,  perhaps,  contrary  to  the 
usual  uotion,  hut  will  he  ai)parent  on  examination  of  hiter  paragraj)lis 
in  this  chai)ter  which  treat  of  the  state  of  the  cervix  before,  during, 
antl  after  labor. 


Figure  297 


Vesico-uterine  fistula  at  angle  of  laceration;  a  rare  condition  which  may  remain  after  partial 
healing  of  an  anterior  laceration.  The  fistulous  tract  has  been  left  after  partial  healing  of  an  anterior 
laceration. 


The  diameter  of  the  cervical  canal  in  the  non-pregnant  uterus  is 
about  one-fifth  of  an  inch.  This  must  be  increased  at  delivery  to 
correspond  to  the  diameter  of  the  child's  head;  it  is,  therefore,  not 
surprising  that  some  degree  of  laceration  occurs  in  labor.  The  lesion, 
however,  is  generally  slight,  and  heals  so  readily  and  rapidly  as  to  cause 
little  or  no  pathological  result. 

TJie  Directions  and  Extent  of  cervical  laceration  vary  within  the 
widest  limits— i.  e.,  the  cer\dx  may  tear  in  any  direction  and  to  any 
extent.    The  usual  directions  are:  anterior,  posterior,  and  lateral. 

Anterior  and  posterior  lacerations,  especially  the  former,  usually 
heal  spontaneously,  and,  therefore,  seldom  are  observed.  This  heal- 
ing is  explained  by  the  anatomical  arrangement  of  the  vaginal  walls, 


548  TRAUMATISMS 

which  tend  to  keep  the  torn  fragments  in  close  contact  while  union 
is  taking  place. 

Anterior  laceration  in  rare  instances  may  extend  so  far  as  to  invade 
the  bladder  and  make  a  vesico-utero vaginal  fistula.  In  such  a  case, 
if  attention  be  paid  to  cleanliness,  considerable  spontaneous  healing 
usually  follows.  There  may  be  left,  however,  a  small  vesicovaginal 
fistula  near  the  cervix  uteri,  or  a  vesico-uterine  fistula  at  the  angle 
of  the  laceration,  extending  from  this  part  of  the  cervical  canal  into 
the  bladder. 

Posterior  lacerations,  extending  into  the  posterior  vaginal  pouch, 
may  open  the  way  for  post-uterine  infection,  and  thus  give  rise  to 
contracting  cicatricial  bands  which  may  draw  the  uterus  downward 
and  backward,  and  fix  it  in  an  intractable  retroversion  or  retroflexion. 
A  variety  of  distressing  and  disabling  functional  disturbances,  includ- 
ing menstrual  disorders,  sterility,  and  extension  of  infection  to  the 
parametria  and  the  peritoneum,  are  among  the  results  which  may 
be  expected  from  this  condition. 

Lateral  lacerations  occur  most  frequently  to  the  left,  less  frequently 
to  the  right  and  left,  least  frequently  to  the  right  of  the  cervix. 

Nature,  instead  of  repairing  the  injury  of  a  lateral  laceration,  resorts 
to  a  deception  so  artful  that,  until  explained  by  Emmet,  the  lesion  had 
been  practically  an  unknown  factor  in  uterine  pathology.  By  this 
deception  a  false  cervix,  composed  chiefly  of  outrolled  intra-uterine  and 
reduplicated  vaginal  tissue,  is  substituted  for  the  normal  cervix.  The 
evidence  of  laceration — that  is,  the  irregular,  fissured,  uneven  appear- 
ance— is  so  obliterated  that  even  the  practised  eye  may  fail  to  recognize 
it.  If  diagnosis  between  the  normal  and  the  lacerated  cervix  were  solely 
dependent  on  sight,  cases  commonly  would  arise  in  which  increased 
size,  congestion,  and  erosion  would  be  the  only  diagnostic  signs. 

The  condition  of  the  cervix  before,  during,  and  after  labor,  as  laid  down 
in  the  following  statement,^  has  a  determining  infiuence  upon  the 
immediate   mechanical   results   of   laceration. 

Before  labor,  from  the  moment  of  the  pregnancy,  the  cervix,  as 
well  as  the  body  of  the  uterus,  enlarges  to  accommodate  the  growing 
foetus.  From  the  first,  the  entire  cervix,  except  a  small  part  which 
surrounds  the  external  os,  expands  SATumetrically  with  the  body 
above.  This  expansion  early  in  pregnancy  obliterates  the  internal  os, 
and  converts  the  entire  cervix  into  an  inverted  dome,  which  projects 
into  the  vagina,  and  whose  walls  are  continuous  with  those  of  the 
corpus.  Thus,  long  before  term,  a  very  large  part  of  the  foetal  cover- 
ing is  composed  of  evolved  and  expanded  cervical  tissue. 

During  labor  there  will  be  some  plane  in  the  cervix  above  which 
the  muscular  wall  of  the  uterus  contracts,  and  below  which  it  dilates, 
for  the  expulsion  of  the  child.  Examination  after  delivery  shows  a 
hard,  contracted,  unyielding  ring.  This  sometimes  has  appeared  to 
the  examiner  to  be  the  contracted  external  os.     It  is,  however,  above 

I  John  Bartlett.  Chicago  Medical  Journal,  October,  1873.  Wilhelm  Braune.  Atlas  of  Topo- 
graphical Anatomy,  Leipsic.    Translation.     Philadelphia,  1877. 


PUERPERAL  LACERATION  OF  THE  CERVIX    ITERI  549 

the  plane  of  the  external  os,  perhaps  even  above  the  uterovaginal 
attaehnient.  The  plates  of  Braune,  drawn  from  frozen  sections  of 
the  pravid  uterus,  show  the  remnants  of  the  internal  os  to  be  on  a 
j)lane  far  above  this  contracted  ring.  It  is,  therefore,  neither  the  con- 
tracted internal  os  nor  the  external  os,  but  is  situated  between  the  two, 
and  is  the  lowest  marj^in  of  the  contracted  part  of  the  uterine  wall. 
It  is  a  temporary  intracervical  os,  below  which  one  must  hjok  for  that 
part  of  the  cervix  which  during  labor  was  compelled  to  undergo  ex- 
cessive dilatation;  and  one  must  ex])ect  there  to  find  laceration  if  it 
be  ])resent. 

Without  care  this  lowest  part  of  the  cervix,  which  has  been  so  stretched 
that  it  cannot  recover  immediately  its  contractile  power,  will  be  over- 
looked. It  can,  however,  always  be  felt  projecting  into  the  vagina  as  a 
"Habby,  floating  collar,"  not  unlike  a  "section  of  large  intestine," 
and  having  even  less  contractible  power  than  the  sphincter  ani  muscle 
after  extreme  forcible  dilatation. 

After  normal  labor  this  lowest  portion  of  the  cervix  slowly  recovers 
its  contractile  power,  and  in  a  few  days  resumes  its  normal  shape, 
and  the  integrity  of  the  external' os  thereby  is  restored. 

In  bilateral  laceration,  nature  has  especially  all  the  conditions  for 
the  formation  of  the  false  cervix  already  mentioned.  The  anterior 
and  posterior  diverging  flaps  of  the  cervix  are  forced  at  once  in  the 
direction  of  least  resistance;  the  former  toward  the  vaginal  outlet, 
the  latter  backward  into  the  posterior  vaginal  fornix.  The  congested 
tissues  about  the  temporary  os,  which  in  the  foregoing  paragraph 
has  been  called  intracer\-ical,  meeting  no  resistance,  now  roll  out. 
This  e version  gives  rise  to  obstruction  in  the  uterine  circulation.  The 
intracervical  structures,  thus  engorged  and  swollen,  no  longer  have 
sufficient  space  for  their  accommodation  within  the  uterus;  hence  the 
eversion  continues  until  tissue  enough  for  the  formation  of  the  false 
cer\'ix  has  been  rolled  out  into  the  vagina,  and  until  the  temporary 
intracervical  os  actually  may  have  usurped  the  place  of  the  now  de- 
stroyed OS  externum.  This  everted  intracer\ical  mucosa,  when  rolled 
out  into  the  hostile  en\-ironment  of  the  vagina,  becomes  infected,  and 
the  infection  may  extend  along  the  mucosa  to  the  endometrium,  Fallo- 
pian tubes,  peritoneum,  and  ovaries;  or  by  continuity  of  the  deeper 
tissues  to  the  myometrium,  perimetrium,  or  parametrium.  Laceration 
of  the  cer\-ix,  therefore,  supplemented  by  infection,  may  open  the  way 
to  extensive  pehdc  disease. 

Subinvolution. — The  physiological  h\"pertrophy  of  pregnancy,  which 
ought  to  subside  after  labor,  under  the  influence  of  infection  may  fail 
to  do  so,  and  may  become  pathological.  Hence  the  uterus  remains 
enlarged;  this  enlargement,  called  subinvolution,  is  a  very  common 
result  of  laceration.  It  usually  pertains  more  to  the  cer\'ix  than  to  the 
corpus  uteri.    See  Chapter  on  Chronic  Metritis. 

Descent  and  Vaginal  Reduplication. — When  the  patient  assumes 
the  upright  position  the  supports  of  the  hea\-y',  congested  subinvoluted 
uterus  are  inadequate  to  hold  it  on  the  normal  level;  it  settles  by  its 


550  TRAUMATISMS 

own  weight  to  a  lower  le\'el  and  carries  with  it  a  reflected  fold  of  the 
vaginal  wall .    See  Figures  303  and  304.    The  vaginal  portion  of  the  cervix 

FiGUEE  298 


The  widely  separated  lips  of  the  recently  lacerated  cervix.  The  posterior  Up  is  crowding  backward 
into  the  posterior  vaginal  fornix,  the  anterior  lip  forward  toward  the  vaginal  outlet.  The  dotted  lines 
show  the  contour  of  the  uterus  and  the  vagina  before  the  laceration.  The  location  of  the  tcmporarj' 
intracervical  os  is  at  the  bottom  or  angle  of  the  laceration. 

FiGUBE  299 


Shows  the  circular  enlargement  of  the  cervix  due  to  outrolling  of  the  intracer\-ical  tissue  and  the 
apparent  elongation  due  to  reduplication  of  the  vaginal  walls.  The  actual  uterovaginal  attachment 
is  at  Z  and  Z.    The  reduplication  makes  it  appear  to  be  at  Z' and  Z'.    See  Figure  301.   . 

thus  is  made  apparently  much  longer  than  it  really  is.    The  soft,  easily 
moulded,  outrolled  intra-uterine  tissue  and  the  reflected  vaginal  waHs 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI 


551 


may  obliterate  completely  the  fissure  which  is  regarded  commonly  as 
the  evidence  of  laceration;  upon  ordinary  examination,  therefore,  the 
tear  may  be  overlooked  entirely.  The  deception  may  be  exposed  by 
placing  the  patient  in  tlie  knee-breast  position.  The  uterus,  by  its 
own  weight,  will  be  carried  then  toward  the  diaphragm;  the  vaginal 
wall  will  unfold  and  disclose  the  true  uterovaginal  attachment;  and 
not  uncommonly  a  deep  laceration  ma}'  be  seen  extending  on  either 
side  far  into  the  vaginal  walls. 


Figure  300 


False  cer\ax  in  unilateral  laceration.    Obliquity  of  the  uterine  axis  from  contraction  of  broad  ligament. 

When  the  laceration  is  confined  to  one  side,  the  deception  of  the 
false  cervix  is  quite  pronounced,  for,  as  shown  by  Emmet,  the  fundus 
in  such  cases  usually  is  drawn  toward  the  affected  side  by  inflammatory 
contraction  of  the  nearest  broad  ligament.  The  effect  of  this  latero- 
version  is  to  raise  the  uninjured  side  of  the  cer\'ix  a  trifle  higher  in 
the  pelvis,  and  correspondingly  to  depress  the  injured  side,  thereby 
causing  a  reflection  of  the  vaginal  wall  on  the  depressed  side,  so  that, 
as  in  the  bilateral  injury,  the  apparent  os  externum  may  seem  to  be 
in  the  very  centre  of  the  cerN^x  when  it  is  really  on  one  side.  To  add 
to  the  confusion,  the  sound,  entering  at  the  side,  may,  though  passing 
to  the  horn  of  the  opposite  side  of  the  uterus,  appear  to  pass  in  the 
median  line. 


552 


TRAUMATISMS 


Cystic  Degeneration. — Puerperal  laceration  of  the  cervix  uteri  causes 
marked  outrolling  of  intra-uterine  tissue  and  consequent  permanent, 
passive  congestion.  The  delicate  intra-uterine  membrane,  instead  of 
being  in  contact  with  the  mild  alkaline  secretion  of  the  uterus  to  which 
it  is  accustomed,  is  in  contact  with  the  irritating  acid  secretion  of  the 
vagina.  But  the  mischief  does  not  end  here.  The  uterine  supports 
soon  may  prove  unequal  to  the  work  of  sustaining  in  position  a  uterus 
heavy  from  congestion,  and  the  uterus  falls  to  a  lower  plane  in  the  pelvis. 
The  everted  membrane,  in  contact  with  the  posterior  vaginal  wall, 
and  constantly  bathed  in  the  vaginal  secretions,  is  subject,  by  reason 
of  the  normal  movements  of  the  uterus,  to  the  additional  irritation 

Figure  301 


Cystic  degeneration.    Double  laceration,  showing  eversion  of  intra-uterine  mucosa  and  enlarged  mucous 

follicles  on  the  false  cervix. 


of  friction.  An  erosion  forms,  and  the  mucous  follicles,  Xabothian 
glands,  estimated  by  Tyler  Smith  to  number  ten  thousand  in  the  normal 
virgin  cervix,  become  diseased.  Some  of  them  pour  out  the  familiar 
thick,  viscid,  ropy,  or  purulent  secretion.  Others,  in  consequence  of 
adhesive  inflammation  which  has  occluded  their  outlets,  become  dis- 
tended by  their  own  secretion  and  undergo  cystic  degeneration.  These 
cysts  are  generally  present,  frequently  in  large  numbers.  Subinvolution, 
including  enlargement  of  the  uterine  blood-vessels,  is  a  natural  sequence 
of  these  changes. 

Thus,  as  already  outlined,  the  false  cervix  is  composed  of: 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI 


553 


Ev'erted  intra-uterine  tissue. 

Reflected  vaginal  wall. 

Cervical    follicles   which    ha\e   undergone   cystic  degeneration. 

Congested  and  inflamed  mucosa  and  submucosa. 

Enlarged  uterine  blood-vessels. 
Hypertrophy  and  Klungaiion  of  the  false  Cervix  are  only  Apparent. — 
Cases  are  frequent  in  whach  there  is  such  apparent  lengthening  of  the 
cervix,  so  that  it  seems  to  extend  from  the  uterovaginal  attachment 
even  to  the  vulva;  the  condition  is  usually  described  as  hypertrophic 
elongation  of  the  cervix.    Credit  for  the  true  explanation  of  this  anomaly 


Figure  302 


Figure  303 


Figure  302. — This  Figure  is  from  a  part  of  an  illustration  in  a  standard  book,  in  which  it  was 
used  to  represent  supposed  infravaginal  h\-pertrophy  of  the  cervnx.  The  vaginal  attachment,  however, 
is  only  apparent,  and  is  due  really  to  reflection  of  the  vaginal  wall  on  a  lacerated  cervix.  The  true 
uterovaginal  attachment  is  shown  at  X  and  X  of  Figure  303.  Figure  303  is  a  correct  representation 
of  the  real  condition. 

FiGUBE  .303. — Shows  the  true  uterovaginal  attachment  at  X  and  A",  and  the  apparent  uterovaginal 
attachment  at  Z  and  Z. 

belongs  to  Emmet.  Figure  303  shows  the  os  externum  on  a  very  low 
plane.  This  is  not  because  the  infravaginal  portion  of  the  cervix 
has  lengthened  by  h\'pertrophy  so  as  to  occupy  the  entire  length  of 
the  vagina,  but  because  the  entire  uterus  has  prolapsed,  carrying  with 
it  a  reduphcated  part  of  the  vaginal  wall,  until  the  os  externum  has 
appeared  at  or  near  the  vulva.  If  the  patient  be  placed  in  the  knee- 
breast  position  and  the  uterus  be  made  to  graA^itate  toward  the  dia- 
phragm, the  reflected  vagina  will  be  unfolded,  the  cervix  will  resume 
its  normal  distance  from  the  \iilva,  and  the  uterovaginal  attaclunent 
will  appear  at  the  proper  distance  from  the  os  externum — that  is,  the 
normal  relations  of  the  vagina  and  uterus  will  be  restored. 

Apparent    elongation    takes    place    occasionally    in    nullipara,    but 
it  is  associated  more  commonly  with  descent  of  the  lacerated  cervix. 
34 


554 


TRAUMATISMS 


The  extent  of  laceration  will  be  apparent  in  proportion  to  the  degree 
of  eversion — that  is,  in  some  cases  the  evidence  of  laceration,  as  already 
explained,  is  obliterated  by  the  outrolled  intra-uterine  tissue;  in  other 
cases  of  less  eversion  the  laceration  is  more  apparent.  A  striking 
illustration  of  the  latter  class  of  cases  is  furnished  by  the  following 
case: 

The  patient  has  been  sent  to  the  hospital  for  amputation  of  a  sup- 
posed "  hypertrophied  cervix."  Superficial  examination  suggested 
the  presence  of  two  large  uterine  polypi,  one  filling  the  anterior  and 


Figure  304 


So-called  hvpertrophic  elongation  of  the  supravaginal  portion  of  the  cervix — rare  except  as  a  post- 
operative condition;  an  explanation  of  this  elongation  as  shown  post-mortem  or  post-operative  is  the 
fact  that  the  cervix  often  becomes  elongated  by  traction  during  the- removal  of  it. 

the  other  the  posterior  half  of  the  vagina,  both  reaching  to  the  vulva; 
further  examination  disclosed  the  apparent  presence  of  extreme  hyper- 
trophy of  the  anterior  and  posterior  lips  of  the  cervix.  Between  these 
two  lips  was  a  fissure  extending  into  the  vagina  for  at  least  two  inches. 
When  the  patient  was  placed  in  the  knee-breast  position,  however, 
the  uterus  gravitated  toward  the  diaphragm;  the  uterovaginal  attach- 
ment appeared  in  its  true  relation,  and  it  was  plainly  to  be  seen  that 
instead  of  hypertrophic  elongation  of  the  infravaginal  portion  of  the 
cervix,  some  degree  of  atrophy  actually  had  taken  place,  for  the  utero- 
vaginal attachment  was  nearer  to  the  external  os  than  normal.    There 


PUERPERAL   LACERATION  OF  THE  CERVIX   UTERI  555 

w<as  a  fissure,  howovor,  disclosing  an  cnormons  bilateral  laceration, 
which  extended  two  inches  into  a  subinvoluted  uterus  and  far  out 
into  the  vaginal  walls  on  either  side.  Repair  of  the  cer\'ix.was  followed 
promptly  by  disappearance  of  all  apparent  elongation,  both  in  the 
infr;naginal  and  supravaginal  portions  of  the  cervix,  and  in  a  few 
weeks  by  complete  subsidence^  of  subinvolution.  In  similar  cases  of 
unilateral  laceration,  with  extreme  eversion,  the  apparently  elongated 
cervix  may  show  no  fissure,  but,  on  the  contrary,  the  erosion  may, 
as  before  stated,  give  to  it  a  symmetrical  form. 

Ainpiit(ifio)i  of  the  cervix  and  hysterectomy  for  so-called  "hyper- 
trophic elongation"  and  "hypertrophic  enlargement  of  its  circumfer- 
ence" have  been  favorite  operations  in  gynecology.  The  true  pathology 
of  this  condition,  however,  would  demand  not  amputation  nor  hyster- 
ectomy, but  closure  of  the  cervix,  if  lacerated,  and  the  appropriate 
treatment  for  displacement. 

The  existence  of  genuine  hypertrophic  enlargement  and  elongation 
of  the  cervix,  although  not  denied,  is  of  rather  rare  occurrence — so 
rare  that  amputation  of  the  cervix,  except  the  removal  of  certain 
diseased  portions,  as  will  be  explained  in  the  operation  for  lacerated 
cervix,  should  become  practically  obsolete.  In  carcinoma  of  the  cervix 
and  in  extreme  inflammatory  infection  of  the  uterus,  not  amputation 
of  the  cervix,  but  hysterectomy  is  the  operation  of  election. 

When  hypertrophic  elongation  of  the  cervix  does  exist,  it  is  above 
the  uterovaginal  attachments,  and  is  therefore  supravaginal.  Infra- 
vaginal  elongation  of  the  cervix — that  is,  elongation  below  the  utero- 
vaginal attachment — is  often  apparent,  seldom  or  never  real. 

A  Cause  of  Carcinoma. — Emmet  first  observed  the  relatively  more 
frequent  development  of  cancer  upon  the  lacerated  cervix  and  the  almost 
entire  absence  of  it  from  the  nulliparous  cervix.  While  we  may  not, 
strictly  speaking,  attribute  cancer  to  laceration  of  the  cervix,  we  must 
not  ignore  the  fact  that  the  irritated  glands  of  a  lacerated  cervix  are  a 
fruitful  soil  for  malignant  disease. 


Symptoms  of  Laceration  of  the  Cervix  Uteri 

Immediately  after  the  accident  occurs,  arterial  hemorrhage  may 
be  so  profuse  as  to  demand  prompt  ligature  and  suture.  The  second- 
ary symptoms  are  those  of  the  pathological  results  of  the  lesion — that 
is,  the  symptoms  of  endometritis,  metritis,  subinvolution,  and  dis- 
placements. The  menorrhagia  and  uterine  discharges  so  common  in 
laceration  are  the  symptoms  of  hemorrhagic  and  catarrhal  or  purulent 
endometritis.  A  variety  of  nervous  symptoms,  such  as  may  be  due 
to  faulty  innervation  and  nutrition,  have  been  attributed  to  laceration 
of  the  cervix.  They  include  neuralgic  and  other  pains  in  remote  parts, 
dyspepsia,  indigestion,  constipation,  menstrual  disorders,  backache, 
and  headache.  Bearing-down  sensations  and  difficulty  of  walking  and 
standing  are  among  the  results  of  the  associated  displacements  of  the 


556  TRAUMATISMS 

pelvic  floor,  which  include  the  uterus,  its  appendages,  the  bladder, 
vagina,  and  rectum,  and  which  often  are  associated  with  laceration. 

Cicatricial  narrowing  of  the  uterine  canal  at  the  angle  of  the  lacera- 
tion may  be  so  extreme,  either  from  natural  contraction  or  from  the 
use  of  caustics,  as  to  reduce  the  uterine  outlet  to  a  mere  pin-point. 
This  reduction  of  caliber  results  in  imperfect  drainage  of  uterine  secre- 
tions. Endometritis  and  numerous  functional  disturbances,  including 
sterility,  dysmenorrhoea,  menorrhagia,  and  amenorrhoea,  are  common 
sequels. 

Emmet  lays  great  stress  upon  the  reflex  irritation  produced  by  the 
cicatricial  plug  in  the  angle  of  the  laceration.  The  cicatrix  develops 
in  an  effort  of  nature  to  close  the  gap,  or  as  a  result  of  the  injudicious 
application  of  caustics.  He  cites  numerous  cases  in  which  severe 
neuralgia  in  distant  organs — for  example,  neuralgia  in  the  eyeball 
— promptly  disappeared  upon  repair  of  the  laceration.  He  attributes 
the  reflex  irritation  to  inclusion  and  pinching  of  nerve-filaments  in  the 
cicatrix,  as  in  the  sensitive  stump  after  amputation  of  the  leg  or  arm. 
The  cicatrix,  therefore,  ma}'  serve  as  a  constant  and  hidden  cause  of 
nerve  irritation.  INIicroscopical  study,  however,  has  failed  to  disclose 
the  pinched  nerve-filaments.  Whatever  may  be  the  explanation  of  the 
facts,  the  clinical  observations  of  Emmet  apparently  have  been  verified 
by  numerous  observers,  for  the  anaemic,  nervous,  neuralgic  state  is 
peculiarly  liable  to  be  associated  with  cicatricial  cervix. 


Diagnosis  of  Laceration  of  the  Cervix  Uteri 

Laceration  of  the  cervix,  until  demonstrated  by  Emmet,  was  known 
only  by  its  effects.  To  designate  the  extent  and  character  of  these 
effects,  the  following  names  which  still  have  descriptive  value  were 
applied:  erosion,  follicular  erosion,  granular  erosion,  papillary  erosion, 
granulation,  excoriation,  ulcer.  Erosions,  when  exaggerated,  were  called 
coxcomb  granulations;  when  the  exaggeration  was  so  extreme  as  to  sug- 
gest malignant  disease,  it  sometimes  was  called  cauliflower  excrescence, 
a  name  loosely  used  also  to  designate  cancer.  Infiammation  of  the  cer- 
vical follicles,  analogous  to  follicular  pharyngitis,  suggested  the  name 
follicular  erosion. 

The  older  text-books  usually  devoted  a  chapter  to  this  subject, 
under  the  head  of  Ulceration  of  the  Womb.  The  disease  is  really  not 
ulceration,  but  erosion.  Ulceration,  except  in  specific  and  malignant 
disease,  rarely  is  found  on  the  cervix. 

The  presence,  after  parturition,  of  a  part  or  all  of  the  elements  which 
compose  the  false  cervix — that  is,  enlargement,  erosion,  eversion, 
and  cystic  degeneration — is  strong  evidence  of  laceration;  cystic 
degeneration  of  the  mucous  follicles  is  almost  pathognomonic  of  lacera- 
tion. The  cysts,  varying  in  size  from  that  of  a  pinhead  to  that  of 
a  small  marble,  feel  to  the  touch  like  shot  scattered  throughout 
the  mucous  tissues  of  the  everted  cervix.     They  rarely  are  found 


PUERPERAL   LACERATION  OF   THE  CERVIX   UTERI 


557 


except  oil  the  lacerated  ccr\ix.  As  explained,  they  are  the  result  of 
occlusion  and  cystic  dc^^encration  of  mucous  follicles,  the  <,dands  of 
Xal)t)th.  These  follicles,  except  in  cases  of  abnormal  distribution, 
are  confined  to  the  intracervical  mucous  membrane,  and  are  not  prone 
to  cystic  degeneration  unless  rolled  out  into  the  hostile  environment 
of  the  vaginal  secretions.  This  outrolling  seldom  occurs  except  as 
the  result  of  laceration.  Hence  cystic  degeneration  without  laceration 
is  rare. 


FiGI-RE    305 


Figure  306 


Figure  305. — Showing  everted,  lacerated  lips  caught  by  tenacula  and  held  apart. 
Figure  306. — Showing  lacerated  lips  caught  by  tenacula  and  roUed  in. 


Laceration,  in  ordinary  cases,  may  be  detected  by  the  educated 
touch  and  sight.  Intelligent  study  of  all  cases,  and  accurate  diagnosis 
in  the  more  obscure,  require  the  cervix  to  be  exposed  by  a  Sims  or  a 
Simon  speculum,  and  the  everted  lips  to  be  caught  and  rolled  in  by 
means  of  two  uterine  tenacula,  one  in  each  hand. 

For  satisfactory  diagnosis,  in  many  cases  the  tenacula  are  essential. 
With  these  instruments  Emmet  was  first  to  solve  what  was  once  a 
knotty  problem,  and  to  revolutionize  the  pathology  and  treatment  of 
this  cervical  disease.  Edmund  Randolph  Peaslee,  referring  to  the 
numerous  cases  of  so-called  ulceration,  said  "they  were  not  recog- 
nized, for  none  of  us  knew  anything  about  them  until  Emmet  told  us. 
It  was  he  who,  in  a  happy  moment,  brought  the  anterior  and  posterior 
surfaces  together  with  tenacula,  and  instantly  demonstrated  that  what 
we  all  supposed  an  ulceration  was  nothing  more  nor  less  than  a  lacera- 
tion."   Figures  301  and  302. 


558  TRAUMATISMS 

I  quote  somewhat  fully  from  Emmet's  first  systematic  paper  on 
this  subject,  because  it  presents  a  graykic  picture  of  the  gynecology  of  the 
last  generation,  and  because  of  the  historical  importance  of  this  epoch- 
making  contribution  to  surgical  literature} 

Differential  Diagnosis  of  Laceration  of  the  Cervix  Uteri 

Laceration  of  the  cervix  uteri  is  to  be  distinguished  especially  from: 

1.  Endocervicitis. 

2.  Congenital  eversion. 

3.  Cancer. 

There  is  a  form  of  erosion  due  to  endometritis,  associated  with  an 
irritating  discharge  from  the  endometrium  or  vagina,  apt  to  occur 
in  feeble  and  poorly  nourished  subjects,  and  not  very  uncommon  in 

'  "November  27,  1862,  I  first  operated  for  the  relief  of  a  double  lateral  laceration  of  the  cervix  by 
freshening  the  surfaces  and  bringing  together  the  anterior  and  posterior  flaps  with  interrupted  silver 
sutures.  This  patient  had  been  an  invahd  for  several  years  before  coming  under  my  care,  and  had 
been  treated  for  menorrhagia  and  hi,^pertrophy  of  the  uterus,  with  an  extensive  erosion.  She  was 
undersize,  of  a  naturally  delicate  constitution,  and  after  a  severe  and  protracted  labor,  with  difficulty 
had  given  birth  to  a  large  child.  Her  general  appearance  indicated  incipient  phthisis,  but  no  evidence 
of  a  tuberculous  deposit  could  be  detected.  The  uterus  was  some  four  inches  in  depth,  and  an  erosion 
extended  about  two  inches  in  diameter  over  an  enormous  cervix.  With  great  care  this  erosion  had 
been  healed  several  times,  by  maintaining  the  recumbent  position  for  a  sufficient  length  of  time,  but 
a  relapse  to  the  former  condition  recurred  in  every  instance  shortly  after  beginning  to  exercise  by 
walking.  I  had  almost  despaired  of  being  able  to  ofier  her  any  permanent  relief,  and  attributed  my 
want  of  success  to  the  condition  of  her  general  health.  While  making  a  digital  examination  one  day 
I  was  puzzled  to  account  for  the  greater  width  of  the  cervix  in  comparison  to  that  of  the  body  be\'ond, 
a  condition  I  had  for  the  first  time  appreciated.  I  placed  her  on  the  left  side  and,  with  Sims'  speculum, 
brought  the  cervix  in  view.  I  drew  the  posterior  hp  forv\-ard  toward  me  with  a  tenaculum,  but  with 
no  special  purpose,  when  I  was  surprised  to  observe  that  it  had  decreased  to  nearly  half  its  previous 
size.  On  hfting  up  the  anterior  lip  with  a  tenaculum  in  the  other  hand,  so  as  to  bring  the  two  portions 
into  approximation,  the  outline  of  a  cervix  presented  of  nearly  normal  size.  The  difficulty  was  at 
once  apparent,  for  the  parts  had  rolled  back  within  the  uterine  canal,  and  a  deep  lateral  fissure  became 
evident,  which  extended  on  each  side  entirely  through  the  cervix  and  beyond  the  vaginal  junction. 
Qn  separating  the  flaps  and  forcing  them  back  to  their  former  position,  I  saw  the  tissues  gradually 
roll  out.  and  the  cervix  again  present  its  previous  appearance.  There  could  then  be  detected  no  appear- 
ance of  laceration,  and  with  the  reduplication  of  vaginal  tissue  over  the  sides  of  the  uterus,  the  cervix 
presented  a  normal  length  above  its  apparent  junction  with  the  vagina.  The  remedy  at  once  suggested 
itself;  the  operation  was  performed  with  the  aid  of  my  assistant,  T)v.  G.  S.  Winston,  and  I  beheve  Dr. 
T.  G.  Thomas  was  also  present.  On  completing  the  operation  the  uterus  was  five  inches  in  depth;  it 
rapidly  reduced  in  size,  and  in  time  all  evidence  of  local  disease  subsided,  but  she  never  entireh-  regained 
her  general  health.  Some  seven  years  after  the  operation  Dr.  F.  N.  Otis,  of  New  York,  her  family 
physician,  detected  a  tuberculous  deposit,  and  she  died  of  phthisis  within  a  few  months,  having  been 
ten  years  under  my  observation.  For  two  years  previous  to  her  death  she  had  resided  abroad,  but, 
as  a  friend,  I  was  kept  advised  of  her  condition,  and  she  continued  free  from  uterine  disease.  I  am 
fully  satisfied  that  at  the  time  of  the  operation  her  condition  was  so  critical  that  it  would  have  been 
but  a  question  of  a  few  weeks  before  a  tuberculous  deposit  would  have  taken  place.  Although  she 
never  recovered  fully  the  loss  of  vitality  to  which  this  injury  had  reduced  her,  yet  her  life  was  beyond 
question  prolonged  many  years  by  the  operation.  " 

After  the  reading  of  this  paper  before  the  New  York  County  Medical  Society,  September,  1874, 
J.  Marion  Sims  said: 

"When  I  went  abroad  in  1862,  among  the  patients  I  turned  over  to  the  care  of  Dr.  Emmet  was  the 
lady  whose  case  forms  the  basis  of  the  paper  I  have  just  read.  She  belonged  to  the  upper  walks  of 
life,  and  had  been  under  my  charge  for  twelve  to  eighteen  months.  I  remember  the  peculiarities  of 
her  case,  so  well  described  by  Emmet,  as  vividly  as  if  it  were  but  yesterday.  The  bilateral  lacerations 
of  the  cervix,  and  the  consequent  eversion  of  the  hypertrophied,  congested  cer\dcal  mucous  mem- 
brane, constituted  at  that  time  a  difficult  problem  to  solve.  During  the  whole  time  that  I  observed 
this  case  no  benefit  resulted  from  local  treatment,  and  I  am  sure  that  nothing  short  of  the  method  so 
successfully  adopted  by  Dr.  Emmet  could  have  been  of  the  least  service  to  her.  I  now  only  wonder 
that  this  operation  had  not  been  worked  out  sooner.  When  the  perineum  is  lacerated,  the  necessity 
for  its  reconstitution  is  self-evident,  and  it  is  singular  that  the  necessity  for  reconstituting  the  integrity 
of  a  lacerated  cervix  did  not  sooner  force  itself  upon  the  surgeon.  The  operation  as  devised  and 
practised  by  Dr.  Emmet  is  as  simple,  as  safe,  and  as  certain  in  its  results  as  is  the  operation  for  a  simple 
case  of  vesicovaginal  fistula.  The  same  principles  underlie  each.  The  same  free  denudation  of  tissue, 
the  same  method  of  suture,  the  same  after-treatment,  and  the  same  security  from  danger  belong  to 
both  alike. 

"1  have  performed  the  operation  often  enough  to  speak  in  positive  terms  of  its  value.  The  discus- 
sion of  the  subject  must,  of  necessity,  be  one-sided.  There  can  be  no  objection,  no  opposition  to  the 
operation.  We  must  accept  it  as  Dr.  Emmet  has  given  it  to  us.  We  cannot  modify  the  operation; 
we  cannot  change  it;  we  cannot  improve  it — for  it  is  perfect;  perfect  in  its  method  and  perfect  in  its 
results. 

"We  owe  to  Dr.  Emmet  a  debt  of  gratitude  for  this  valuable  contribution  to  uterine  surgery.  Like 
all  new  operations,  it  is  likely  to  be  abused;  but  the  time  will  soon  arrive- when  it  will  assume  its  place 
in  the  foremost  rank  of  useful  improvements." 


PUERPERAL    I.ACERATIOX  OF   TIIK  CERVIX    CTERI  559 

virgins;  tlu-  coiiditiitii  is  ;iiialoi,M»iis  to  tlu-  I'aniiliar  rn)>inii  ami  cxccjriation 
product'd  l)y  prolonged  iia>al  discliarucs  on  tlic  iipj)iT  lips  of  children. 
Such  an  cTosion  is  distinj^uishrd  readily  from  that  of  laceration  by 
absence  of  eversion,  by  the  absence  of  marked  cervical  enlargement, 
by  the  presence  of  a  normally  shaped  os  externum,  and  b\-  physical 
examination  soon  to  be  described.  The  treatment  is  that  of  the  causa- 
tive endometritis. 

Congenital  eversion  of  the  non-lacerated  cervical  mucosa  may  occur 
in  rare  cases.    It  has  been  observed  even  in  infancx'. 

The  disease  most  liable  to  be  mistaken  for  laceration  is  beginning 
cancer  of  the  cervix.  A  careful  reading  of  the  description  of  this  dis- 
ease will  help  to  show  the  difference  between  the  two  conditions.  Can- 
cer bleeds  freely  on  slight  abrasion,  is  extremely  friable,  does  not 
readily  permit  inroUing  with  tenaciila,  and  rapidly  goes  on  to  ulcera- 
tion.    Laceration  presents  none  of  these  characteristics. 

Prophylaxis  of  Laceration  of  the  Cervix  Uteri 

The  prophylaxis  consists  in  the  avoidance  of  all  measures  calcu- 
lated to  hasten  unduly  the  normal  progress  of  labor— that  is,  the 
avoidance  of  meddlesome  manipulations  of  digital  or  instnunental 
interference.  A  precipitate  labor  should,  if  practicable,  be  retarded. 
The  relative  disproportion  between  the  child  and  the  cer\'ix  may  render 
all  precautions  useless  and  laceration  inexdtable. 

Treatment  of  Laceration  of  the  Cervix  Uteri 

The  Operation  of  Trachelorrhaphy. ^  —  It  is  not  necessarily  the 
extent  of  laceration,  but  rather  the  degree  of  outrolling  that  indicates 
the  necessity  for  repair.  A  relatively  slight  laceration  may  give  rise 
to  extreme  eversion,  and  consequently  to  all  of  the  pathological  changes 
above  described,  which  belong  to  the  false  cer\-ix.  Furthermore, 
slight  laceration  T\-ithout  eversion  may,  if  associated  with  great  cica- 
tricial formation  or  cystic  degeneration,  give  rise  to  very  distressing 
symptoms.  On  the  other  hand,  a  deep  laceration  may  cause  little 
or  no  disturbance. 

Immediate  Operation  of  Trachelorrhaphy. — Some  obstetricians  urge 
immediate  closure  of  the  torn  cervix  uteri.  The  operation,  if  successful, 
would  have  the  same  advantages  as  immediate  perineorrhaphy — that 
is,  less  danger  of  infection  through  the  exposed  surfaces,  relief  from 
long-continued  dread  of  operation,  and  freedom  from  the  evil  eflFects 
of  any  pathological  changes  consequent  upon  delay.  There  is,  however, 
great  difficulty  in  recognizing  the  limit  of  the  fresh  tear  in  the  loose 
folds  of  the  divulsed,  soft,  flabby  cervix  and  the  surrounding  upper 
end  of  the  vagina.  The  exact  relations  of  the  torn  vaginal  wall  to  the 
cervix  are  also  difficult  to  define:  for  these  reasons  accurate  adjustment 

'  E.  C.  Dudley,  of  Chicago,  former  interne  at  the  Woman's  Hospital  in  the  State  of  Xew  York,  was 
the  first  to  designate  this  operation  trachelorrhaphy.    Emmet's  Principles  and  Practice  of  Gj-necologj-. 


560  TRAUMATISMS 

of  the  torn  surfaces  may  be  difficult.  The  immediate  operation,  there- 
fore, unless  necessitated  by  profuse  arterial  hemorrhage,  is  of  ques- 
tionable propriety;  when  it  is  performed  the  continuous  catgut  suture 
should  be  used. 

Secondary  Operation  of  Trachelorrhaphy. — In  order  to  avoid  out- 
rolling,  subinvolution,  cystic  degeneration,  endometritis,  metritis, 
descent  and  other  pathological  changes,  early  repair  of  the  extensively 
torn  cervix  is  desirable.  The  operation  is  permissible  as  soon  as  the 
cervix  has  recovered  from  the  immediate  effects  of  extreme  divulsion, 
and  has  regained,  so  far  as  the  injury  will  permit,  its  normal  form — 
that  is,  at  the  end  of  two  or  three  months.  Unfortunately,  in  the 
majority  of  cases,  the  lesion  is  not  recognized  or  brought  to  the  attention 
of  the  gynecologist  until  the  resultant  pathological  changes  have 
impaired  the  health  of  the  patient.  It  is  the  duty  of  the  accoucheur, 
and  is  one  of  the  imperative  requirements  of  modern  scientific  mid- 
wifery, to  make,  in  the  second  or  third  week  of  the  puerperium,  an 
examination  of  the  pelvic  organs  to  determine  the  existence  of  any 
pathological  condition  which  may  demand  attention. 

Preparatory  Treatment  of  complicating  displacements  and  erosions, 
although  advised  by  many,  is  not  usually  imperative.  The  treatment 
of  a  displacement  may  be  necessary  after  the  operation,  and  may 
be  deferred  properly  to  that  time.  Associated  endometritis  should  be 
treated  by  preliminary  curettage  as  a  preparatory  step  in  the  opera- 
tion for  closure  of  the  laceration.  If  the  eroded  cervix  be  greatly 
thickened  or  complicated  by  extensive  cystic  degeneration,  the  diseased 
tissues  should  be  removed  by  Schroeder's  method.     Figures  314  to  316. 

It  is  difficult  to  discriminate  between  certain  inflammatory  condi- 
tions in  the  pelvis  which  contraindicate  trachelorrhaphy.  The  opera- 
tion, if  performed  in  a  case  of  acute  pelvic  inflammation,  is  liable  to  be 
followed  by  general,  possibly  fatal,  pelvic  infection,  and  therefore  is 
contraindicated.  The  presence,  in  the  pelvis,  of  structures  which  are 
thickened,  h\^ersensitive,  or  adherent — or,  in  other  words,  the  non- 
purulent results  of  chronic  inflammation — does  not  necessarily  contra- 
indicate Emmet's  operation.  On  the  contrary,  the  improved  uterine 
drainage  secured  by  the  preliminary  dilatation,  the  removal  of  the 
products  of  endometritis,  and  of  the  original  source  of  the  pelvic 
infection  by  thorough  curettage  of  the  inflamed  endometrium,  and  the 
rolling  in  of  the  irritable  everted  cervical  mucosa,  may  be  the  most 
effective  treatment  for  such  pelvic  inflammations. 

PuNCTUEiNG  OF  Cysts. — The  follicular  retention-cysts  already 
described,  if  present,  will,  unless  properly  treated,  render  the  operation 
for  closure  of  the  cervix  not  only  useless,  but  also  injurious.  In  fact, 
these  diseased  glands  if  rolled  into  the  cervical  canal  by  trachelorrhaphy 
are  liable  to  enlarge,  multiply,  and  remain  a  hidden  source  of  irritation. 
Often  they  are  so  numerous  and  of  such  large  size  as  to  lead  to  the 
suspicion  of  cancer.  If  few  in  number  and  superficial,  they  may  be 
punctured,  or  the  projecting  part  of  the  cyst-wall  may  be  caught  with 
a  tenaculum  and  removed  by  the  scissors  and  the  remaining  part  of 


PUERPERAL  LACERATION  OF   THE  CERVIX   UTERI         561 

the  cyst-wall  then  destroyed  by  nitric  acid  or  the  galvanocautery. 
Several  such  treatments  may  be  reciuircd  before  the  cervix  is  ready 
for  operation.  Extenalrc  cystic  (hcelopmciii,  especially  on  the  thickened 
cervix,  extending  up  into  the  cervical  canal,  requires  excision  of  the 
diseased  tissue.  Simple  puncturing  of  the  cysts  by  the  spear-pointed 
lance  is  inadequate  because,  unless  the  secreting  surface  be  destroyed,  the 
cysts  are  prone  to  refill.    See  Schroeder's  operation.    Figures  314  to  317. 

Figure  307 


Manner  of  denudation  with  uterine  tenaculum  and  Emmet's  curved  scissors.      One  side  denuded, 
the   other  partlj^  denuded.      Left   lateroprone  position;   exposure   by   Sims'    speculum. 

Many  operators  prefer  Simon's  to  Sims'  speculum;  the  writer 
uses  either  indifferently.  The  majority  of  surgeons  probably  prefer 
Simon's  retractor  to  Sims'.  Education  and  habit  will  fix  the  choice, 
which  should  be  limited  to  these  two  instruments.  The  needle  with 
bayonet  trocar,  or  glover's  point,  is  preferable  to  that  with  the  round 
point;  the  latter  is  difficult  to  introduce  through  the  indurated  tissue 
without  breaking.  The  full-curved  needle  is  unmanageable;  the  force 
required  for  its  introduction  is  exerted  in  the  line  of  a  tangent  to  the 
curve,  and  is  therefore  more  liable  to  break  the  needle  than  when 


562 


TRAUMATISMS 


exerted  in  the  direct  line  of  the  straight  needle.  It  may  also  be  difficult 
to  estimate  the  location  of  the  point  of  a  curved  needle.  There 
are  practical  advantages  in  a  needle  slightly  curved  at  the  point,  but 
otherwise  straight. 

Disinfection. — Under  ansesthesia,  the  patient  being  on  her  back,  the 
vagina  and  external  genitals  are  scrubbed  thoroughly  with  water  and 
green  soap.    When  the  soap  has  been  washed  off  with  hot,  sterilized 

Figure  308 


Shows  the  surface  denuded  and  two  sutures  in  place,  but  not  tied.    Left  lateroprone  position;  exposure 

by  Sims'  speculum. 


water,  the  disinfection  is  completed  by  an  additional  washing  with  a 
1 :  2000  alcoholic  solution  of  bichloride  of  mercury.  A  conjoined 
examination  is  made  now  in  order  to  obtain  information  of  any  con- 
dition w^hich  before  anaesthesia  may  have  been  overlooked.  This 
examination,  since  it  occasionally  reveals  conditions  which  may  modify 
or  contraindicate  the  operation,  is  important.  If  no  contraindication 
for  the  operation  appears,  the  cervix  is  exposed  by  Sims'  or  Simon's 
speculum,  and  the  uterus  dilated,  curetted,  washed  out,  and  treated 
with  an  intra-uterine  application  of  tincture  of  iodine,  which  disinfects 
the  endometrium  and  decreases  the  risk  of  infection.     The  objects 


PUERPERAL    LACERATIOX   OF   THE   CERVIX    fTERI  rAVA 

of  (lilatatioii  and  curcttafie  arc:  1,  to  i)revt'nt  infection  of  the  wound 
and  failure  of  union  from  contact  of  the  patlioh)^ical  secretions  of  a 
possil)ly  diseased  endometrium;  2,  to  secure  efficient  draina<;e  of  tiie 
endometrium  and  therehy  to  i)re\ent  the  retenticMi,  stagnation,  decom- 
position, and  alisorption  of  its  secretions;  o,  to  avoid  leaving  an  infected 
endometrium,  which,  after  closure  of  the  cervix,  mijjht  by  extension 
invoh'c  the  ]:)arametria,  uterine  appenda,<res  and  peritoneum. 

Approximation. — Before  proceeding  to  the  c-l(jsing  of  the  cer\ix,  a 
careful  study  should  be  made  of  the  direction  or  directions  and  extent 
of  the  rupture,  by  trial  approximations  of  the  torn  fragments  in  various 
ways  with  a  tenaculum  in  each  hand.  If  there  be  a  simple  bilateral 
laceration,  the  operation  will  be  as  follows: 

Denudation. — With  the  tenaculum  and  curved  scissors  the  surfaces 
to  be  united  are  denuded.  Figure  307.  Inasmuch  as  an  important 
function  of  the  cervical  canal  is  drainage,  it  is  essential  to  leave  a 
wide  and  free  outlet  at  the  external  os.  To  this  end,  that  portion  of 
the  undenuded  mucosa  which  is  to  line  the  restored  external  os  should 
be  left  .wide,  so  that  when  united  the  normal  trumpet-shape  of  the 
lower  segment  of  the  cerWcal  canal  will  be  preserved.  Immediately 
after  the  operation  the  diameter  of  the  restored  external  os  should  be 
even  larger  than  normal,  so  that  the  involution  that  follows  the  opera- 
tion will  reduce  it  ultimately  to  the  normal  caliber.  Figures  308  and  311 
show  the  properly  curved  lines  between  the  denuded  and  undenuded 
surfaces.  Extreme  stenosis  at  the  external  os,  sometimes  amounting 
to  complete  atresia,  is  a  possible  result  of  inattention  to  this  important 
detail. 

Among  the  consequences  of  stenosis  and  obstruction  in  the  uterine 
canal  are  the  following: 

1.  Retention  and  decomposition  of  uterine  secretion  and  men- 

strual fluid. 

2.  Possible  destruction  of  the  Fallopian  tubes. 

3.  ^Metritis,  endometritis,  and  salpingitis. 

The  conditions  mentioned  above  may  give  rise  to  immediate  disas- 
trous results,  or  may  cause  persistent  invalidism.  The  rapid  and  com- 
plete relief  which  often  follows  the  reopening  of  a  contracted  cervical 
canal  and  os  externum  proves  that  the  integrity  of  the  uterine  canal 
as  a  natural  drainage-tube  is  essential  to  health. 

Removal  of  the  Cicatricial  Plug. — The  denudation  should  always 
include  removal  of  the  plug  of  cicatricial  tissue  which  usually  forms 
the  angle  of  the  laceration.  Tliis  important  step  in  the  operation,  if 
disregarded,  may  prevent  easy  approximation  of  the  denuded  surfaces, 
cause  the  sutures  to  cut  out  from  undue  tension,  and  result  in  failure 
of  union  or  in  imperfect  union.  Failure  of  union,  however,  under  such 
conditions  would  be  a  fortunate  compromise  for  the  patient,  since  the 
cicatrix  is  much  less  injurious  with  the  laceration  open  than  closed. 
^^^len,  fortunately,  union  has  taken  place,  the  consequent  train  of 
nervous  symptoms  may  necessitate  reopening  of  the  wound  and  removal 
of  the  cicatricial  plug. 


564 


TRAUMATISMS 


Hemorrhage. — The  usual  slight  bleeding  is  controlled  readily  by 
sponge  pressure.  Arterial  hemorrhage,  if  not  controlled  by  forci- 
pressure  or  torsion,  may  require  a  fine  catgut  ligature.  In  occasional 
aggravated  cases  the  bleeding  must  be  checked  by  the  application  of 
one  or  two  deep  sutures. 

Figure  309 

C 


A  line  connecting  Y,  X,  and  Z  would  represent  angle  of  laceration;  X,  section  of  uterine  canal  at  angle 
of  laceration.     Three  of  the  sutures  in  place.     Diagrammatic. 


Figure  310 


Sutures  in  place  on  one  side  ready  to  tie.     Diagrammatic. 

The  Sutures  may  be  of  chromic  catgut  or  silkworm-gut.  .  Silkworm- 
gut  remains  aseptic  longer,  and  is  therefore  superior  to  catgut.  If 
the  perineum  is  closed  at  the  same  time,  the  difficulty  in  the  removal 


PUERPERAL  LACERATION  OF   THE  CERVIX   UTERI         565 

of  the  cervical  sutures  will  justify  the  use  of  absorbable  catgut,  which 
does  not  have  to  be  removed.  Catgut  may  also  be  used  in  tlie  repair 
of  all  small  lacerations,  especially  where  the  surfaces  readily  fall  together 
and  remain  in  apposition  without  traction.  The  catgut  should  be  so 
chromici/ed  that  it  will  resist  absorption  for  twenty  days.  In  order 
that  sutures  may  not  convey  possil)le  infection  to  the  wound,  they 
should,  as  in  all  plastic  surgery,  so  far  as  practicable,  be  passed  under  and 
not  through  the  denuded  surfaces.  This  principle  is  illustrated  by  the 
dotted  lines  in  Figure  309;  the  surface  between  the  lines  AB  and  CD 
is  left  undeinided,  to  form  that  part  of  the  cervical  canal  which  is  to  be 
restored.  The  two  sutures  indicated  on  one  side  show  the  location 
of  the  sutures  near  the  angle  of  laceration;  and  the  one  on  the  oppo- 
site side  shows  the  location  of  the  sutures  at  the  os  externum.  When 
all  the  sutures  have  been  tied,  they  will  bring  the  surface  A  YXZC 
in  contact  with  the  surface  B  Y X ZD  in  such  a  manner  that  point  A 
will  coincide  with  point  B,  and  point  C  with  point  D.  The  lines  A  C 
and  B  D  will  then  bound  the  restored  external  os. 

Figure  311 


Showing  the  rolling-in  effect  of  the  operation.     Sutures  tied.     Diagrammatic. 

Figure  310  shows  the  same  laceration  from  another  point  of  view. 
The  sutures  on  one  side  are  represented  as  all  ha\'ing  been  introduced 
before  any  are  tied.  This  was  the  plan  formerly  pursued  when  the 
silver  suture  was  used.  It  is  better  to  tie  the  silkworm  gut  or  catgut 
sutures  as  they  are  introduced.  Figure  311  shows  the  sutures  tied, 
the  everted  mucosa  rolled  in,  and  the  operation  complete. 

A  study  of  Figures  310  and  311  ^^'ill  disclose  an  interesting  fact  in 
the  mechanics  of  laceration  and  trachelorrhaphy.  If  in  the  subinvo- 
luted  uterus  represented  by  Figure  310  the  distance  from  the  angle  of 
laceration,  X,  to  the  fundus  is,  say,  three  inches,  and  the  distance  from 
the  angle  of  laceration  to  the  margin  of  the  torn  lip  is  one  inch,  it 


566  TRAUMATISMS 

would  appear  reasonable  to  assume  that  the  uterine  canal,  when  fully- 
restored,  would  measure  four  inches.  Accurate  measurements  of  the 
uterine  canal,  however,  before  and  after  operation  almost  always  show 
a  decrease,  not  an  increase,  in  length.  In  a  uterus  of  such  dimen- 
sions, the  canal,  after  operation,  usually  would  measure  not  four,  but 
about  two  and  three-quarters  inches.  The  explanation  of  this  decrease 
is  as  follows: 

As  shown  in  the  pathology,  the  intra-uterine  mucosa  rolls  out,  and 
the  lowest  portion  of  the  uterine  canal  becomes  the  external  os  of  the 
lacerated  cervix,  point  X,  Figure  311.  In  tying  the  first  suture-points 
1  and  1  are  not  only  brought  together  to  form  one  and  the  same 
point,  but  all  mucosa  above  this  suture  is  at  the  same  time  rolled 
into  the  uterine  canal,  so  that  point  X  moves  up  and  point  1  takes  its 
place.  On  the  successive  tying  of  the  other  sutures,  2,  3,  4,  and  5, 
the  same  mechanical  result  is  observed,  so  that  finally  suture  5,  when 
tied,  occupies  the  place  formerly  occupied  by  X.  All  the  mucosa 
between  1  and  5  on  one  side  and  1  and  5  on  the  other  is  now  rolled 
into  the  uterine  canal  above  the  original  level  of  point  X.  This 
mechanical  result  alone  abundantly  justifies  the  operation;  it  also 
verifies  the  propositions  laid  down  in  the  preceding  paragraphs  on  the 
mechanical  results  of  the  lesion. 

The  reasons  for  so  great  a  decrease  in  the  length  of  the  uterine  canal 
may  not  be  wholly  apparent  from  the  foregoing.  The  following  reasons, 
in  addition  to  the  rolling-in  of  the  everted  tissue  are  therefore  sub- 
mitted: loss  of  blood  and  tissue  in  denuding;  evacuation  or  removal 
of  retention-cysts;  contraction  of  muscular  fibres  due  to  the  stimulus 
of  the  operation;  and,  above  all,  relief  from  congestion,  which  naturally 
follows  restoration  of  everted  intra-uterine  structures  to  their  normal 
position  inside  of  the  uterus.  The  outrolled  structures  before  the 
operation  had  been,  so  to  speak,  in  a  state  of  erection. 

Operation  for  Atypical  Lacerations. — The  closure  of  a  unilateral, 
anterior,  or  posterior  laceration  follows  the  rules  already  laid  down  for 
simple  bilateral  injuries.  Stellate  lacerations  in  some  cases  may  be 
treated  by  closure  of  each  individual  tear;  or,  if  two  are  very  near 
together,  they  may  be  changed  into  one  by  removal  of  the  intervening 
tissue.  There  may  be  one  or  two  major  and  several  minor  rents;  in 
such  a  case  the  surgeon  sometimes  may  disregard  the  small  fissures, 
and  by  rolling  in  the  everted  cervix,  as  indicated  by  the  deeper  tears, 
find  that  the  smaller  ones  disappear  within  the  canal,  and  may  therefore 
be  ignored  in  the  operation.  It  is  impossible  to  anticipate  every 
variation  in  the  direction  and  effect  of  the  injury.  Each  atypical 
case  must  be  treated  according  to  the  special  requirements. 

Resection  of  the  Cervix. — In  a  large  proportion  of  cases  of  laceration 
of  the  cervix  the  lesion  is  unrecognized,  neglected,  or  unskilfully  treated, 
so  that  extensive  pathological  changes  occur.  These  changes  may  pre- 
vent or  contraindicate  the  rolling-in  of  the  diseased  tissues;  or,  if  the 
cervix  has  been  closed  improperly,  may  require  it  to  be  reopened  and 
closed  again  correctly.     The  changes  are: 


rri'Jh'I'Kh'AL    LACK/i'ATlOX   OF   TIIK   CEIIVIX    (TPJRI 


r)()7 


1.  Great  thickeiiinu-  and  induration  ol'  tlic  laccratt'd  lijjs,  wliicli,  it' 
possible  to  roll  into  the  uterine  eanal  at  all,  would  eause  traetion  ui)on 
the  sutures,  and  result  in  their  eutting  out;  or,  if  union  should  oeeur, 
the  induration  and  thiekeninji;  might  persist  and  give  inereased  trouble. 

2.  Extensive  eystic  degeneration  of  the  Nabotliian  follieles.  The 
evil  results  of  rolling  these  cysts  into  the  cervical  canal  have  been 
mentioned. 

Figure  312 


Left  lateroprone  position;  exposure  by  Sims'  speculum.  The  sutures  tied  and  the  cervix  united, 
as  seen  looking  through  the  speculum  into  the  vagina.  Notice  the  lines  of  union  running  from  the 
OS  over  the  cer\ax  across  the  uterovaginal  attachment  into  the  reflected  vaginal  wall.  In  this  case, 
as  in  all  others,  a  great  part  of  the  tear  is  in  the  vaginal  walls. 

3.  Endocervicitis,  with  deep  involvement  of  the  ce^^'ical  glands,  and 
a  consequent  profuse  discharge  of  a  ropy,  tenacious,  gelatinous  secre- 
tion. The  only  satisfactory  treatment  of  this  condition  is  excision  of 
the  diseased  structures.  Their  destruction  by  the  cautery  or  sharp 
curette  is  apt  to  be  followed  by  contraction  and  stenosis  of  the  cervix, 
and  is  therefore  objectionable. 

4.  Stenosis  in  the  lower  portion  of  the  cer\'ical  canal  and  os  externum. 
This  condition  may  be  due  to  too  tight  closure  of  the  cervix  or  to  cica- 
tricial contraction  from  curettage,  cauterization,  or  other  causes. 


568 


TRAUMATISMS 


Under  the  conditions  named  above,  the  diseased  tissue  should  be 
removed    by    resection    of    the    cervix — Schroeder's    operation.^     The 


Figure  313 


Introduction  of  a  suture  with  the  patient  in  the  dorsal  position  and  the  cervix  exposed  by  means 
of  Simon's  retractor — retractor  not  shown — counterpressure  by  the  index  finger.  The  illustration 
shows  in  the  lower  left-hand  corner  counterpressure  by  means  of  the  tenaculum. 


''  _  1  Emmet  had  for  many  years  before  the  publication  of  Schroeder's  operation  performed  an  opera- 
tion in  principle  like  Schroeder's,  but  differing  in  technique. 


PUERPERAL   LACERATIOX  OF   THE  CERVIX   UTERI 


5t)9 


tt'(hni(iiie  of  the  operation  is  as  follows:    The  diseased  tissue  is  removed 

by  iiK'isions  as  indicated  by  the  dotted  lines  in  Fi<j;ure  314,  the  vaginal 


Figure  314 


Shows  a  thickened  diseased  cervix  requiriag  resection.    The  dotted  lines  indicate  the  directions  of  the 

incisions. 

Figure  315 


Shows  the  diseased  tissues  excised  and  sutures  in  place,  but  not  yet  tied,  to  unite  the  vaginal  margin 
to  the  cervical  margin  of  the  wound. 


margins  of  the  wound  then  are  stitched,  both  anteriorly  and  posteriorly, 
with  fine  chromicized  catgut,  to  the  margins  of  the  intracervical  mucous 
membrane.    By  this  means  the  anterior  and  posterior  lips  of  the  cervix 
35 


570 


TRAUMATISMS 


are  folded  upon  themselves.  Figure  315.  The  first  stage  of  the  opera- 
tion is  now  complete,  and  the  condition  becomes  that  of  an  uncompli- 
cated bilateral  laceration.  The  remainder  of  the  operation  is  the  same 
as  that  of  trachelorrhaphy,  already  described. 


Figure  316 


Anterior  and  posterior  vaginal  margins,  each  turned  into  the  cer^acal  canal  and  united  by  means 
of  fine  catgut  sutures  to  the  intracervical  margins  of  the  wound.  Lateral  surfaces  denuded  and  sutures 
placed  as  in  ordinary  trachelorrhaphy,  but  not  yet  tied. 

Before  proceeding  to  excision  of  the  diseased  structures,  it  is  often 
necessary  to  supplement  Schroeder's  operation  by  deep  lateral  incisions 
with  the  scissors.  By  this  means  the  anterior  and  posterior  lips  may  be 
separated  widely  far  up  into  the  uterine  canal,  and  the  diseased  struc- 
tures  thoroughly   inspected   and   efficiently   removed.     The   diseased 


Figure  317 


All  sutures  tied;  operation  complete. 


The  white  dots  in  the  os  represent  the  protruding  intracervical 
sutures. 


tissue  is  removed  best  by  seizing  it  in  small  vulsellum  forceps  or  a 
tenaculum  and  cutting  it  out  with  two  or  three  strokes  of  the  scissors. 
The  frequent  closure  of  the  lacerated  cervix  without  the  removal  of 
these  diseased  structures  accounts  for  numerous  failures  and  disappoint- 
ments in  the  operation. 


PVKRl'KRM.    LACERATION  OF   THE  CERVIX   UTERI         571 

The  brief  rejiort  of  a  siii<2;le  ease'  will  serve  to  illustrate  the  importance 
of  resection.  'rracliclorrJiaphy  had  been  performed  ten  years  previously. 
From  tiu'  time  of  that  ()])eration  the  patient  had  suffered  from  pro- 
nounced cataK'psy,  with  frecpient  paroxymss.  Examination  showed 
an  enormously  thickened  cerxix  with  a  j^inhole  os.  IJoth  ovaries  were 
enlar<:;ed  slif2;htly  and  adherent.  In  order  to  ascertain  the  condition 
of  the  interior  of  the  cervix,  very  deep  bilateral  incisions  were  made: 
the  interior  and  i)osterior  lips  were  sei)arated  more  widely  than  would 
be  usual  in  an  extensive  laceration  of  the  cervix.  Much  pent-up  secre- 
tion which  escaped  showed  that  the  tight  closure  of  the  os  externum 
had  converted  the  whole  endometrium  into  a  retention-cyst.  Numerous 
cysts  of  the  Xabothian  follicles,  superficial  and  deep,  large  and  small, 
appeared  in  the  intra  cervical  mucosa  and  submucosa.  In  excision  of 
these  cysts  the  cervical  mucosa  and  submucosa  were  removed  almost 
to  the  internal  os;  the  vaginal  and  intracervical  margins  of  the  wound 
were  unitefl  with  catgut  sutures,  as  shown  in  Figure  315.  What 
remained  of  the  lateral  incisions  was  closed  then  with  interrupted 
silkworm-gut  sutures.  The  operation,  except  the  very  deep  lateral 
incisions,  was  practically  that  of  Schroeder.  Since  recovery  from  the 
operation  the  patient,  though  naturally  neurotic,  has  reported  herself 
free  from  cataleptiform  seizures. 

The  After-treatment  of  trachelorrhaphy,  or  Schroeder's  operation, 
consists  of  rest  in  bed  for  about  ten  days,  a  vaginal  douche  of  hot 
sterilized  water  twice  daily,  and  removal  of  the  sutures  through  Sims' 
or  Simon's  speculum  in  about  two  weeks.  If  the  perineum  and  cer^'ix 
are  closed  at  the  same  time,  the  pressure  of  the  speculum  during  the 
removal  of  the  cervical  sutures  does  not,  with  careful  manipulation, 
endanger  the  freshly  united  perineum,  provided  the  perineal  sutures 
are  still  in  place;  if  they  have  been  removed,  it  is  necessary  to  delay 
removal  of  the  cervical  sutures  until  the  perineal  union  is  solid — that  is, 
for  an  additional  two  or  three  weeks.  It  is  better,  however,  in  the  double 
operation,  as  already  stated,  to  use  in  the  cervix  absorbable  catgut 
sutures,  which  do  not  have  to  be  removed  at  all. 

Results. — Trachelorrhaphy  in  suitable  cases,  properly  performed 
with  due  regard  to  asepsis,  is  one  of  the  most  satisfactory  operations 
in  gynecology.  I^nion  by  first  intention  is  the  almost  invariable  rule. 
The  relief  from  symptoms  is  often  very  great. 

Disappointment  in  the  operation,  as  already  stated,  may  result. 

1.  From  neglect  to  treat  the  complicating  endometritis. 

2.  From  the  rolling-in  of    hopelessly  diseased  structures,  -which 

ought  to  have  been  excised. 

3.  From  disregarding  such  contraindications  as  pelvic  suppuration. 

4.  From  closing  the  os  externum  so  tightly  as  to  obstruct  the 

natural  outflow  of  uterine  secretions. 

5.  From  the  unwise  selection  of  cases. 

6.  Above  all,  from  faulty  technique  in  the  operation  itself. 

'  Dudley.     "The  Abuse  of  Emmet's  Operation  for  Laceration  of  the  Cervix."     Journal  of  the 
American  Medical  Association,  September  23,  1893. 


CHAPTER  XXXVII 
GENITAL  FISTULiE 


Priority  in  the  Operation  for  Genital  Fistulas 

Up  to  forty  years  ago,  when  the  operation  for  the  closure  of  vaginal 
fistulse  was  developed  and,  in  practical  form,  given  to  the  world  by  J. 
Marion  Sims,  these  most  distressing  injuries  had  been  incurable.    The 

Figure  318 


Vesico-uterine   fistula.      Vesico-uterovaginal   fistula.     Vesicovaginal   fistula.      Urethrovaginal  fistula. 
Rectovaginal  fistula.     Perineo-anal  fistula.     Anal  fistula. 

invention  of  Sims'  speculum,  which  made  the  operation  possible,  has 
a  significance,  however,  more  far-reaching  than  the  mere  recognition  of 
a  valuable  operation,  for  it  marks  an  epoch  in  the  history  of  gynecology. 
The  operation  furnished  the  initiative  for  the  period  of  great  practical 
(572) 


GENITAL  FISrUL/E  573 

acti\ity  \vliicJi  followed.  It  will  in  no  respect  detract  from  the  credit 
which  justly  heloiitis  to  the  <rreat  ])i()iieer  if  we  admit  the  fact  that  tiie 
honor  of  perfecting  and  perpetuating  the  methods  upon  which  his 
oijeration  was  based,  and  upon  which  modern  gynecology  has  made 
its  greatest  development,  must  he  di\ided  between  J.  Marion  Sims  and 
Thomas  Addis  Emmet. 

Varieties  of  Genital  Fistulae 

A  fistulous  opening  may  connect  the  interior  of  the  uterus  or  vagina 
with  some  part  of  the  urinary  or  intestinal  tract.  Accordingly,  the 
varieties  of  genital  fistulse  are  urinary  fistulse  and  fecal  fistulae. 

Figure  315  shows  the  more  common  varieties  of  genital  fistuhe. 
They  are: 

Vesicovaginal  fistula.  Urethrovaginal  fistula. 

Vesico-uterine  fistula.  Rectovaginal  fistula. 

Vesico-utero vaginal  fistula. 

The  following  other  forms  are  of  rare  occurrence:  The  ureter  may 
communicate  directly  with  the  vagina,  making  a  uretromginal  fistula. 
The  ureter  may  open  into  the  margin  of  a  vesicovaginal  fistula,  making 
a  uretero-vesicovaginal  fistula.  Various  other  rare  forms,  such  as  uretero- 
uterine  fistula,  should  be  classed  as  surgical  ciu-iosities. 

The  causes  of  genital  fistulse  are  these: 

Impaction  of  the  presenting  part  during  labor  and  consequent 
pressure-necrosis. 

Direct  traumatism  as  in  unskilful  forceps  operation. 

Congenital  causes — that  is,  defective  development. 

Ulcerative  and  other  destructive  processes  from  SAphilis,  cancer, 
and  inflammation. 

Burrowing  of  pus  from  abscess. 


VESICOVAGINAL  FISTULA 

The  definition  of  the  lesion  is  apparent  from  the  name — that  is,  an 
opening  between  the  bladder  and  vagina. 

Etiology  of  Vesicovaginal  Fistulae 

In  the  vast  majority  of  cases  the  lesion  results  from  impaction  of 
the  presenting  part  during  labor  and  consequent  pressure-necrosis  in 
the  vesicovaginal  wall.  Completion  of  the  necrotic  process  and  separa- 
tion of  the  slough  require  from  five  to  twelve  days;  hence,  in  fistula 
from  this  cause  the  essential  symptom,  escape  of  urine  through  the 
vagina,  does  not  occur  until  several  days  after  labor. 

A  fistulous  opening  sometimes  is  made  purposely  by  a  surgical 
operation  for  the  treatment  of  cystitis  or  for  the  removal  of  stone  in 
the  bladder,  or  it  may  be  the  result  of  accidental  traumatism.     The 


574  TRAUMATISMS 

escape  of  urine  will  then  be  immediate.  Congenital  fistula  is  rare, 
and  is  characterized  by  the  involuntary  escape  of  urine  from  the  time 
of  birth.  The  ulcerative  processes  of  syphilis,  cancer,  and  inflammation 
are  much  more  frequently  the  cause  of  fecal  than  of  urinary  fistula. 

Symptoms  and  Course  of  Vesicovaginal  Fistulse 

The  constant  symptom,  already  mentioned,  is  the  escape  of  urine 
from  the  bladder  through  the  vagina.  The  fistula  may  vary  from' 
the  size  of  a  pin-point  to  that  of  the  entire  vesicovaginal  wall.  When 
the  opening  is  of  appreciable  size  or  large,  the  flow  of  urine  usually  is 
continuous.  In  very  small  fistulse  the  escape  of  urine  may  be  inter- 
mittent. The  intermission  is  apt  to  occur  when  the  woman  is  lying 
down.  In  rare  cases  of  small  fistula  a  valve-like  formation  may  shut 
off  the  flow  of  urine  except  when  the  woman  assumes  certain  positions 
favorable  to  its  escape. 

A  Cause  of  Cystitis. — In  the  majority  of  cases  there  is  more  or  less 
residual  urine  in  the  bladder.  This  is  a  good  culture-medium  for  bacteria 
which  now  find  ready  access  from  the  vagina  to  the  bladder;  hence, 
cystitis  is  a  usual  complication.  From  this  cause  the  urine  becomes 
alkaline,  ammoniacal,  and  excessively  irritating.  The  vagina,  external 
genitals,  thighs,  and  buttocks,  over  which  it  flows,  become  excoriated, 
cedematous,  and  ulcerated.  A  gritty,  offensive  phosphatic  deposit 
may  form  and  deeply  incrust  not  only  these  surfaces,  but  also  the 
raw  margins  of  the  fistula  and  the  bladder  mucous  membrane.  This 
deposit  is  especially  apt  to  accumulate  and  form  incrustations  on  ulcer- 
ated and  otherwise  exposed  surfaces.  It  may  fiU  the  vagina  and  even 
extend  over  the  ulcerated  labia.  The  inside  of  the  bladder,  perchance 
deeply  ulcerated,  granulating,  incrusted,  bleeding,  and  excessively 
painful,  may,  in  rare  cases,  if  the  fistula  be  large,  become  inverted 
and  protrude  in  a  semi-strangulated  condition  between  the  labia  majora. 
The  patient,  within  a  few  weeks  after  labor,  will  then,  unless  great  care 
is  exercised,  become  an  object  of  loathing  or  pity. 


Diagnosis  of  Vesicovaginal  Fistulse 

The  opening,  if  sufficiently  large,  may  be  felt  by  the  finger  in  the 
vagina.  The  fistula,  thus  having  been  located,  the  finger  may  be  used 
as  a  guide  for  the  passage  of  a  sound  through  the  urethra  into  the 
bladder,  and  thence  through  the  fistulous  opening  into  the  vagina. 

^^Tlen  the  fistula  is  very  small,  it  is  sometimes  difficult  or  impossible 
to  see  it  even  after  careful  search  with  the  speculum.  In  such  a  case, 
the  speculum  being  in  place,  the  bladder  should  be  injected  through 
the  urethra  with  sterilized  colored  water.  The  point  at  which  this 
fluid  escapes  into  the  vagina  will  locate  the  fistula.  The  differential 
diagnosis  from  uretero vaginal  fistula  would  give  negative  results  on 
injection  of  the  bladder.     See  ureterovaginal  fistula. 


GENITAL   FI.HTULM  575 

Prognosis  of  Vesicovaginal  Fistulae 

Tlu'  prounosis  depends  upon  the  extent  of  tlic  injury,  the  amount 
of  cicatricial  tissue,  and  the  difficulty  of  api)roxiniating  the  margins 
of  the  fistula.  In  exceptional  cases  of  small  openings,  in  which  the 
margins  lie  in  easy  and  close  apposition,  they  may,  if  kept  clean,  soon 
unite  without  operative  interference.  The  vast  majority  of  fistuhe, 
however,  unless  united  by  suture,  are  permanent. 

Prophylactic  Treatment  of  Vesicovaginal  Fistulae 

The  statistics  of  Emmet,  co\'ering  a  long  series  of  cases  of  vesico- 
vaginal fistula,  show  that  the  average  duration  of  labor  from  the  time 
of  rupture  of  the  membranes  to  the  birth  of  the  child  w'as  between  two 
and  three  days.  Statistics  further  prove  that  impaction  and  conse- 
cjuent  continued  pressure  of  the  presenting  part  upon  the  ^•esicovaginal 
septum,  even  for  a  few  hours,  are  very  liable  to  result  in  cutting  oflF  the 
circulation  and  in  consequent  death  and  sloughing  of  the  compressed 
tissue.  //,  therefore,  in  any  case  impaction  becomes  apioarent  by  the 
failure  of  the  presenting  part  to  admnce  during  the  pains  and  to  recede 
in  the  interval  between  the  pains,  delivery  should  be  hastened  and  terminated 
without  unnecessary  delay.  The  possible  danger  of  a  forceps  operation 
in  such  a  case,  even  by  the  inexperienced  hand,  when  compared  with 
the  danger  of  fistula,  would  be  insignificant. 

Emmet's  records  show  that  in  nearly  all  his  cases  parturition  had 
taken  place  either  without  attendance  or  under  the  care  of  ignorant 
midwives.  In  some  cases  labor  had  terminated  finally  by  the  unaided 
efforts  of  nature,  and  in  others  by  the  use  of  the  forceps.  In  the  latter 
class  of  cases  delivery  is  accomplished  usually  by  a  consultant,  who 
is  not  called  until  after  prolonged,  continuous  pressure  has  destroyed 
the  vitality  of  at  least  a  part  of  the  vaginal  wall.  Sometimes  the 
fistula  is  attributed  wTongly  to  the  forceps  or  other  instruments, 
instead  of  the  real  cause — prolonged  pressure — a  cause  which  earlier 
interference  would  have  prevented.  As  Thomas  wisely  remarks,  the 
truth  on  this  point  should  be  set  forth  clearly  to  the  friends  of  the 
patient  before  forceps  are  applied,  "for  unless  it  be  so,  an  incom- 
petent person  may  shield  himself  from  merited  blame  by  casting 
censure  upon  a  consulting  physician,  by  whose  efforts  the  lives  of  both 
mother  and  child  may  have  been  saved;  and  thus  a  skilful  operator 
may  suffer  unjustly  in  a  suit  for  malpractice." 

Emmet's  statistics  show  that  in  a  large  proportion  of  cases  the 
bladder  was  not  emptied  during  the  progress  of  labor.  This  neglect 
would  cause  large  accumulation  of  retained  urine  and  great  distension 
of  the  bladder.  The  result  would  be  paralysis  of  the  bladder  and 
cystitis.  Moreover,  the  impaction  would  be  increased  by  the  pressure 
urine  exerted  on  the  bladder  side  of  the  vesicovaginal  septum,  and  this 
pressure  would  be  an  additional  cause  of  necrosis.  Catheterization, 
therefore,  as  a  prophylactic  measure  is  an  urgent  necessity. 


576  TRAUMATISMS 

After  delivery  in  a  case  ot  continuous  and  prolonged  impaction, 
decided  antiseptic  measures  are  indicated  to  prevent  or  limit  the 
threatened  necrosis.    They  are: 

1.  A  vaginal  douche  of  0.5  per  cent,  lysol,  or  some  other  appro- 
priate antiseptic,  every  eight  hours. 

2.  Daily  washing  out  of  the  bladder  with  a  saturated  solution  of 
boric  acid. 

3.  Sufficiently  frequent  catheterization  to  prevent  great  accumula- 
tions of  urine  and  consequent  bladder  distension. 

Surgical  Treatment  of  Vesicovaginal  Fistulas 

The  surgical  treatment  includes  the  preparatory  treatment,  the 
operation,   and  the  after-treatment. 

Preparatory  Treatment. — If  the  parts  are  brought  into  a  condi- 
tion favorable  for  union,  the  operation  for  the  cure  of  vesicovaginal 
fistula,  even  with  ordinary  skill,  is  one  of  the  most  satisfactory  in  the 
whole  field  of  surgery.  On  the  other  hand,  the  most  skilful  operation, 
with  faulty  preparation,  is  almost  certain  to  fail. 

Phosphatic  Deposits. — The  margins  of  the  fistula  cannot  be  brought 
into  a  healthy  condition  and  made  fit  for  union  until  the  phosphatic 
deposit  already  mentioned  has  been  removed,  and  the  further  forma- 
tion of  it  prevented.  To  this  end,  the  urine  should  be  rendered  acid; 
otherwise  the  deposit  will  accumulate  on  the  sutures  and  in  the  lines 
of  union,  and  cause  the  operation  to  fail.  It  does  not,  however,  develop 
in  acid  urine.  Emmet's  mixture  of  benzoic  acid,  2  drachms;  borax, 
3  drachms;  and  cinnamon  water,  12  ounces,  gives  uniformly  good 
results.  A  tablespoonful,  further  diluted,  should  be  taken  four  times 
a  day  until  the  urine  becomes  mildly  acid.  The  dose  then  should 
be  regulated  to  maintain  normal  acidity  and  to  avoid  deranging  the 
digestion.  The  acid  sodium  phosphate  in  30  grain  doses,  well  diluted, 
is  most  useful  to  render  the  urine  acid.  In  order  to  dilute  the  urine  and 
render  it  less  irritating,  pure  water  should  be  given  quite  freely.  If 
the  urine  is  kept  slightly  acid  and  well  diluted,  the  phosphatic  deposit 
once  removed  will  not  return. 

The  removal  of  the  deposit  is  accomplished  best  by  means  of  a 
dressing-forceps,  or  it  may  be  brushed  off  with  a  wad  of  cotton  in  the 
grasp  of  the  forceps,  after  which  the  raw  surfaces  should  be  treated  by 
means  of  a  solution  of  silver  nitrate,  ten  grains  or  more  to  the  ounce, 
on  an  applicator  wound  with  absorbent  cotton.  Sometimes  the  deposit 
adheres  very  firmly,  as  if  it  were  interlaced  with  the  adjacent  and 
underlying  tissue,  so  that  immediate  removal  would  be  too  difficult 
or  painful.  Emmet  then  applies  a  stronger  solution  or  even  the  solid 
stick  of  silver  nitrate  to  the  deposit  itself.  This  may  be  repeated 
every  few  days  until  the  deposit  is  detached. 

The  hot  vaginal  douche  described  in  Chapter  IV.  is  of  the  utmost 
value  in  the  preparatory  treatment.  It  should  be  given  freely  several 
times  a  day,  and  large  quantities  of  hot  water  should  be  used.    This 


GENITAL   FISTUL/E  577 

part  of  the  treatment,  as  Emmet  declares,  is  indispensable.  The  sitz- 
l)ath  also  is  most  useful  and  uTateful  to  the  patient.  The  douche  may 
be  gi\en  to  advantage  and  with  increased  comfort  while  the  jxitient 
is  in  the  sitz-bath.  This  treatment,  merel\'  insuring  perfect  cleanliness, 
has  resulted  in  some  cases,  even  of  large  fistula,  in  spontaneous  closure. 
They  were  cases,  however,  in  which  there  had  not  been  great  loss  of 
tissue,  and  in  which  the  edges  of  the  fistula  were  in  apposition. 

The  excoriated  or  eroded  surfaces  about  the  nates  or  thighs  are 
treated  best  by  frequent  bathing,  followed  by  applications  of  ben- 
zoated  zinc  oxide  ointment.  Napkins  like  menstrual  napkins  should 
be  worn  over  the  vulva  to  absorb  the  urine,  and  should  be  changed 
frequently;  otherwise  the  urine  which  they  hold  will  decompose  and 
become  excessi\-ely  irritating  to  the  skin.  Points  of  ulceration  may  be 
touched  with  solid  silver  nitrate. 

Cystitis,  if  present,  is  a  clear  contraindication  to  immediate  closure 
of  the  fistula.  The  copious  hot-water  vesicovaginal  douche,  frequent 
and  prolonged,  is  the  best  means  of  treating  this  complication.  It  is 
given  as  an  ordinary  vaginal  douche,  except  that  the  hot  water,  instead 
of  being  thrown  in  by  the  douche  point  through  the  vulva,  is  introduced 
through  the  urethra.  For  this  purpose  a  glass  urethral  catheter  or 
cannula  small  enough  to  enter  the  urethra  is  used  in  place  of  the  vaginal 
douche  point.  The  hot  water  by  this  means  is  applied  first  freely  to 
the  bladder,  and  then  through  the  fistula  to  the  vagina  and  vulva. 
Cystitis  in  these  cases,  as  already  explained,  is  sometimes  the  result 
of  residual  urine.  It  may  therefore  be  necessary,  especially  in  a  very 
small  fistula,  to  secure  adequate  drainage  of  the  bladder  by  an  incision 
in  the  vesicovaginal  wall.  If  the  fistula  is  situated  in  or  near  the  median 
line  of  the  vesicovaginal  septum,  the  incision  should  be  so  made  as  to 
enlarge  it,  otherwise  an  independent  opening  should  be  made.  See 
Treatment  of  Cystitis  by  INIeans  of  Artificial  A'esicovaginal  Fistula, 
in  Chapter  XXI.  Old  inflammation  of  the  kidney  or  ureter  may  be 
present,  and  if  in  an  advanced  stage  might  contraindicate  the  operation ; 
hence  the  importance  of  the  rule  to  examine  the  urine  in  every  case. 
The  urine  may  be  collected  for  examination  by  keeping  the  woman 
on  a  bed-pan  until  a  sufficient  quantity  has  accumulated. 

Stone  in  the  Bladder,  free  or  encysted,  may  in  rare  cases  have  ante- 
dated and  even  been  a  cause  of  fistula — that  is,  the  vesicovaginal 
septum  during  labor  may  have  been  compressed  between  the  stone 
and  the  child's  head.  Usually,  however,  the  calculus  is  deposited 
from  the  residual  urine  already  mentioned  as  among  the  frequent  results 
of  fistula.  The  necessity  for  the  removal  of  such  a  stone  before  closing 
the  fistula  is  apparent. 

Direction  and  Manner  of  Closure. — The  urine  being  normal,  the  vagina 
and  bladder  healthy,  and  the  structures  surrounding  the  fistula  fit  for 
union,  the  next  step  will  be  to  decide  upon  the  best  direction  and  manner 
of  closure.  In  order  to  preserve  the  length  of  the  vagina,  it  is  desirable, 
if  possible,  to  bring  the  parts  together  from  side  to  side,  so  as  to  make 
a  line  of  union  as  nearly  as  possible  in  the  long  axis  of  the  vagina.    A 


578 


TRAUMATISMS 


line  of  union  transversely  across  the  vagina  would  shorten  its  anterior 
wall  and  would  draw  down  the  uterus  and  fix  it  in  permanent 
displacement. 

Unfortunately,  in  many  cases  of  extensive  sloughing  the  margins 
of  the  fistula  cannot  be  approximated  from  side  to  side.  They  may 
even  be  so  held  apart  by  cicatricial  bands  that  they  cannot  be  approxi- 
mated at  all,  for  there  may  not  be  sufficient  tissue  left  to  fill  the  gap. 
In  order  to  decide  upon  the  best  mode  and  direction  of  closure,  the 
fistula  should  be  exposed  by  Sims'  speculum,  and  its  margins  at  dift'erent 


FiGrRE  319 


Vesicovaginal  fistula  exposed  by  Sims'  speculum.     Approximation  of  the  margins  attempted  by  means 
of  tenacula.     Left  lateroprone  position. • 

points  seized  on  opposite  sides  and  drawn  together  with  a  tenaculum 
in  each  hand.  In  this  way  one  may  judge  of  the  amount  of  force 
required  to  approximate  the  edges,  and  of  the  direction  in  which  they 
will  come  together  with  the  least  traction. 

It  is  an  urgent  rule, never  to  introduce  sutures  unless  the  surface  to  he 
united  can  he  held  in  contact  without  traction;  even  a  little  traction  on 
the  sutures  will  cause  them  invariably  to  cut  out  and  the  operation  to  fail. 

1  Emmet.     Principles  and  Practice  of  Gynecology. 


GENITAL   FISTULyE 


579 


If  the  rostrainiiig  hands  nrv  so  li^ht  and  superficial  that  moderate 
traction  with  tenacula  suffices  to  ai)i)ro.\iniate  the  marf^ins  of  the 
fistuhi,  the  hands  may  he  (Uvidcd  with  scissors  until  the  marjijins  reachly 
fall  together.  The  surfaces  then  may  be  denuded  immediately  and 
the  sutures  introduced. 

If  the  sloughing  has  been  very  extensive,  one  or  more  prehminary 
operations  may  be  necessary.  Emmet  places  the  patient  on  her  back, 
introduces  two  fingers  of  the  left  hand  into  the  rectum,  and  the  thumb 
of  the  same  hand  into  the  vagina.  The  interior  of  the  vagina  thereby 
is  rolled  out  and  exposed  without  a  speculum.  The  right  index-finger 
in  the  vagina  now  detects  the  points  of  greatest  cicatricial  tension. 
Point  after  point  is  snipped  with  the  blunt  scissors  in  such  a  way  as 
to  render  the  margins  of  the  fistula  more  readily  approximated.    If  the 

Figure  320 


Sims'  glass  vaginal  plug 


cervix  uteri  has  sloughed,  the  relations  of  the  remaining  portion  of  the 
uterus  to  the  upper  part  of  the  vagina,  even  by  rectal  touch,  may  be 
difficult  to  make  out.  There  is  then  great  danger  of  wounding  a  mis- 
placed ureter  or  of  entering  the  peritoneum.  This  danger  is  lessened 
by  the  careful  use  of  the  sound  in  the  bladder  held  by  the  hand  of  an 
assistant. 

If  the  restraining  bands  have  been  divided  as  freely  as  may  be  deemed 
prudent  and  still  the  margins  cannot  be  approximated,  Emmet  directs 
that  a  Sims  glass  or  hard-rubber  vaginal  plug  be  introduced  and  held 
in  place  by  a  T-bandage.  It  should  be  sufficiently  long  and  wide  to 
keep  the  vagina  well  stretched  both  longitudinally  and  laterally,  and 
to  control  hemorrhage  by  pressure,  but  not  so  large  as  to  cause  pressure- 
necrosis  and  sloughing.     Under  this  pressure,  absorption  of  cicatricial 


580 


TRAUMATISMS 


tissue  is  rapid.  The  continued  stretching  of  the  vagina  also  increases 
its  cahber  and  renders  approximation  of  the  margins  of  the  fistula 
less  difficult.     The  dilator  may  have  to  be  retained  for  several  weeks 


Figure  321 


1,  2,  and  3,  4,  represent  the  restraining  cicatrical  bands  on  each  side  of  the  fistula;  a  b  and  e  f  show  the 

lines  of  incision. 

until  the  incisions  have  healed  over  it;  in  the  meantime  it  may  be 
removed  daily  for  cleansing  douches.  The  patient  should  be  kept  in 
bed  for  a  week  or  two  after  this  preliminary  operation.    After  healing 

Figure  322 


The  wounds  made  by  incisions  a  b  and  e  f  are  drawn  widely  apart  by  tenacula  so  as  to  give  the  wound 
on  either  side  the  direction  of  c  d  and  y  h.     Sutures  are  in  place  on  right  side. 

has  taken  place,  the  operation,  if  necessary,  may  be  repeated;  if  the 
margins  of  the  fistula  can  be  brought  together  without  tension,  the 
sutures  for  closure  may  be  introduced. 

Figure  323 


Incised  wounds  on  both  sides  of  the  fistula  closed  at  right  angles  to  lines  of  incision.  The  edges  of 
the  fistula  now  readily  fall  into  apposition.  Sutures  for  closure  of  fistula  in  place,  and  two  of  them 
tied. 


In  place  of  the  incisions  and  glass  dilator  just  described,  the  restrain- 
ing cicatricial  bands  may  be  divided  deeply  and  freely  and  the  wounds 
closed  at  right  angles  to  the  lines  of  incision.  The  operation  is  illifs- 
trated  in  Figures  321,  322,  and  323.    This  preliminary  plastic  work 


GENITAL  FISTULA  581 

may,  according  to  indication,  be  done  at  the  time  of  closing  the  fistula 
or  as  a  separate  operation. 

The  prej)aratory  treatment  outlined  above  may  be  difficult,  long- 
continued,  and  most  trying  to  patient  and  surgeon.  Fortunately, 
there  are  many  cases  in  which  it  is  not  required.  When  it  is  required, 
the  most  skilful  operation  will  fail  without  it. 

Figure  324 


The  use  of  the  uterine  tenaculum  and  Emmet's  scissors  in  denudation.     Left  lateroprone  position; 

exposure  by  Sims'  speculum. 

The  Operation  for  Closing  the  Fistula. — This  involves  a  considera- 
tion of  the  following  topics: 

1.  General  preparatory  treatment. 

2.  Choice  of  speculum  and  method  of  operation. 

3.  Choice  of  direction  for  closure  of  the  fistula. 

4.  Denudation. 

5.  Introduction  of  sutures. 

6.  After-treatment. 


582 


TRAUMATISMS 


1.  The  General  Preparatory  Treatment  and  arrangement  for  plastic 
operations  described  in  Chapter  II.  are  applicable  and  adequate  for 
this  operation. 

2.  Choice  of  Speculum  and  Method  of  Operation. — The  author's  choice 
between  the  method  of  Simon,  with  the  patient  in  the  dorsal  position, 
the  parts  being  exposed  by  numerous  vaginal  retractors,  and  the 
method  of  Sims,  with  the  left  lateroprone  position  and  Sims'  speculum, 

Figure  325 


The  proper  area  of  denudation.     The  denuded  surfaces  correspond  to  the  deck  and  the  fistula  to  the 
manhole  of  a  canoe.     Left  lateroprone  position;  exposure  by  Sims'  speculum. 


is  based  upon  an  extensive  experience  with  both  methods.  The  Simon 
method  is  serviceable  and  adequate  for  the  ordinary  case,  but  not 
always  for  difficult  cases.  This  is  especially  true  when  the  fistula  is 
near  the  vaginal  outlet  behind  the  ramus  of  the  pubes.  In  fat  subjects, 
moreover,  the  Sims'  position  and  speculum  are  almost  indispensable. 
Decided  preference  therefore  is  given  to  the  method  of  Sims  as  taught 
and  practised  by  Emmet.  The  position  of  the  patient  and  the  use  of 
the  speculum  are  described  in  Chapter  III. 


GENITAL  FISTULA 


583 


;>.  Direction  of  the  Line  of  Union. — In  order  to  decide  upon  the  exact 
direction   for   closure,   the   edj^es   of  the   fistuhi   are   approximated    in 


FlClKK    .il'l 


a,  this  cut  is  suggested  by  a  similar  one  in  a  standard  work,  and  shows  how  the  denudation  should 
not  be  made.  The  scissors  are  preferable  to  the  knife  and  the  tenaculum  to  the  forceps;  b.  c.  when  the 
fistula  is  made  in  this  way  there  is  apt  to  be  failure  of  union  at  the  puckered  ends  of  the  united  wound. 

different  ways  with  tenacula,  until  that  direction  is  found  and  adopted 
which  permits  the  margins  of  the  fistula  to  be  approximated  with  the 
least  traction.     For  reasons  already  given,  it  is  always  desirable  to 


584 


TRAUMATISMS 


make  the  line  of  union,  if  possible,  in  the  direction  of  the  long  axis 
of  the  vagina. 


Figure  327 


A  CORRECT   METHOD  OF  OPERATING, 
b 

a 


a,  correct  method  of  denudation  with  tenaculum  and  scissors;  6,  correct  form  of  denuded  surface. 
First  suture  being  introduced  for  closure  of  fistula  in  direction  of  long  axis  of  vagina;  c,  same  as  b, 
with  closure  of  fistula  completed;  d,  first  suture  being  introduced  for  closure  of  fistula  in  transverse 
axis  of  vagina;  e,  same  as  d,  with  closure  of  fistula  completed. 

4.  Denudation. — The  edges  of  the  fistula  are  denuded  by  means  of 
the  tenaculum  and  scissors,  as  shown  in  Figure  324. 
The  skilful  hand  will  denude  superficially  or  deeply,  as  may  be 


GENITAL  FISTULA  585 

required.  The  denuded  surfaces  should  he  made  ek'an  and  smooth, 
and  tlie  hleedin<;'  sliouhl  he  shj^ht.  For  denuchition  tlie  uterine  ten- 
aeuhun  and  seissors  are  far  superior  to  the  tissue  forceps  and  the 
scalpeh 

The  margins  of  the  fistuhi  are  seized  with  the  tenacuhun,  at  the  point 
nearest  the  operator,  and  a  strip  is  cut  away  all  around  the  opening. 
It  is  highly  important  that  broad  surfaces  be  secured  for  ai)proximation; 
hence  it  may  be  necessary  to  remove  one  or  more  additional  strips 
around  the  opening.  If  sloughing  has  left  the  edges  about  the  fistula 
quite  thin,  the  denuded  surfaces  should  be  correspondingly  broader. 

Figure  328 

-V ^^  ^  , V 

B '         « B- 

Ordinary  denudation:     l',  V,  vaginal  surface;  B,  B,  vesical  surface;  C  and  Z),  lines  of  denudation. 

The  two  points  upon  which  to  lay  the  greatest  stress  are,  first,  adequate 
preparatory  treatment;  second,  broad  surfaces  for  union.  The  fistula 
may  be  so  small  as  to  be  inaccessible  for  denudation,  and  therefore 
may  have  to  be  enlarged  by  incision  in  order  that  its  margins  may  be 
freshened  and  united. 

Some  operators  instead  of  denuding,  split  the  edges  of  the  fistula. 
This  method,  though  not  usual,  is  yet  highly  advantageous  when  the 
margins  are  thin,  or  when  it  is  especially  desirable  to  economize  tissue. 
See  Figures  328  and  329.  The  bladder  mucosa,  if  cut,  is  prone  to 
bleed  freely;  hence,  denudation  should  ordinarily  extend  to  but  not 

Figure  329 


B ^       J> -B- 

Flap-splitting  on  both  sides  seldom  required:    V,  V,  vaginal  surface;   B,  B,  vesical  surface;  C,  C,  and 
D,  D,  inner  surfaces  of  split  edges  to  be  coapted. 

into  it.  Hemorrhage  from  the  cut  bladder  mucosa,  even  in  the  careful 
hands  of  Emmet,  has  twice  been  so  free  as  to  distend  the  bladder 
with  blood  and  endanger  life.  In  both  cases  the  sutures  were  removed 
and  the  bleeding  points  secured.  "\Mien  the  denuded  strip  includes 
the  bladder  mucous  membrane,  the  cut  margin  may  retract  into  the 
bladder  and  make  the  bleeding  points  quite  inaccessible.  Complete 
ansesthesia,  a  strong  light,  good  position,  and  the  skilful  use  of  the  spec- 
ulum and  uterine  tenacula  may  then  be  necessary  to  evert  and  expose 
bleeding  surfaces  and  control  hemorrhage. 

Emmet  properly  condemns  the  practice  of  simply  denuding  a  strip 
36 


586 


TRAUMATISMS 


of  uniform  width  around  on  the  vaginal  side  of  the  fistula.  He  insists 
that  the  margins  be  denuded  to  the  vesical  mucosa.  The  denudation 
at  the  angles  of  the  fistula  should,  however,  be  extended  some  distance 
over  the  vaginal  surface,  as  shown  in  Figure  325.  Otherwise,  there 
will  be  a  double  fold  or  pucker  at  each  angle.  One  may  illustrate  this 
by  picking  up  together  two  small  folds  of  a  napkin,  and  observing 
that  they  extend  a  considerable  distance  before  they  can  be  smoothed 
down  to  the  common  surface.    The  same  is  true  of  the  vaginal  folds  at 

Figure  330 


Closing  of  a  vesicovaginal  fistula;  introduction  of  a  suture.     Left  lateroprone  position;  exposed  by 

Sims'  speculum. 


the  two  ends  of  an  improperly  denuded  fistula,  and  the  denudation 
should  therefore  be  so  extended  that  the  folds  are  lost  on  the  level  of 
the  vagina.  Unless  this  precaution  is  observed,  union  is  apt  to  be 
imperfect,  or  may  fail  altogether  at  the  ends  of  the  line  of  union. 

5.  Application  of  Sutures. — Formerly  the  metallic  suture,  usually 
silver,  was  almost  exclusively  used.  Now,  with  aseptic  methods,  any 
suture  is  adequate.  Most  surgeons  prefer  silkworm-gut  tied  on  the 
surface  with  an  ordinary  hard  knot.    The  numerous  devices  for  fastening 


CEMTAL   FISTL'L.K 


587 


the  sutures  by  means  ol'  short  nu-taHic  plates,  (juills,  spht  shot,  and  other 
means  are  useless,  harmful,  or  unnecessary. 

Emmet's  or  Sims'  needk'  is  aihipted  best  for  ordinary  use;  it  is  short 
and  straight,  except  near  the  point,  where  it  is  curved  sHj^litly.  Occa- 
sionally a  full-cur\ed  needle  may  be  of  service.  The  Emmet  needle 
is  shown  in  Figure  3o(). 

A  needle-forceps  without  locking  is  recommended  because  it  will 
enable  a  dexterous  operator  constantly  to  vary  the  direction  of  the 
needle  during  introduction. 

The  suture  should  be  attached  to  the  needle  in  the  ordinary  way, 
as  a  thread  is  attached  to  a  common  sewing-needle.  The  needle  is 
grasped  by  the  forceps  and  entered  about  one-eighth  of  an  inch  from 
the  margin  of  the  fistula  on  the  vaginal  side;  it  transfixes  the  vesico- 
vaginal wall  and  emerges  on  the  bladder  side,  so  as  barely  to  include 
the  vesical  margin;  it  then  is  passed  through  the  wall  on  the  opposite 
side  in  the  inverse  order,  and  brought  out  one-eighth  inch  from  the 
margin  of  the  vaginal  mucosa  on  that  side.  The  sutures  should  be 
placed  about  one-sixth  of  an  inch  apart.  If  silver  sutures  are  used, 
they  all  should  be  passed  first  and  then  secured  by  twisting.  In  using 
silkworm-gut,  one  usually  should  tie  each  suture  as  it  is  passed.  Let 
the  sutures  be  tied  just  tightly  enough  to  hold  the  parts  together. 
If  tied  too  tightly,  they  strangulate  the  tissues,  cut  out,  and  fail  to 
give  union. 

A  clot  of  blood,  if  left  in  the  bladder  after  closure,  may  cause  great 
vesical  tenesmus  and  possibly  imperil  the  result.  It  is  well,  therefore, 
before  tying  the  final  sutures  to  throw  a  quantity  of  sterilized  water 
through  the  urethra  into  the  bladder.  This  water  will  pass  through 
the  fistula  into  the  vagina  and  wash  out  anything  remaining  in  the 
bladder. 

Figure  331 


Sims'  sigmoid  catheter. 


6.  After-treatment. — The  patient  is  placed  in  bed  on  the  back,  with 
a  roll  under  the  knees  for  support.  A  self-retaining  Sims'  sigmoid 
catheter  is  placed  in  the  urethra;  it  should  be  made  of  block-tin  or  of 
glass,  bent  by  the  fiame  of  a  spirit  lamp.  The  curves  should  be  adjusted 
to  the  indi^^dual  case.  The  urine  passes  through  the  catheter  and  is 
collected  in  a  urinal  placed  between  the  thighs.  The  catheter  is  apt 
to  become  clogged  with  mucus  or  blood-clots,  and,  therefore,  should 
be  removed  and  cleaned  every  few  hours.  A  second  catheter  is  desirable, 
in  order  that  one  may  always  be  introduced  as  soon  as  the  other  is 
removed.    In  case  of  a  small  fistula  we  may  dispense  sometimes  ^sith 


588 


TRAUMATISMS 


the  self-retaining  catheter  altogether  and  permit  the  patient  to  pass  the 
urine  in  the  natural  way.  Both  patient  and  nurse  should  be  cautioned 
to  see  that  the  flow  of  urine  is  not  interrupted.  The  catheter  should 
remain  about  fourteen  days.  The  sutures,  unless  removed  earher  on 
account  of  suppuration  or  failure  of  union,  may  remain  two  or  three 
weeks.  The  woman  should  be  kept  in  bed  a  week  longer,  and  dmung 
this  time  should  be  catheterized  at  frequent  intervals. 

Figure  332 


\ 

'^ 

^^ 

ii>i. 

"  ■  n 

\ 

s 

» 

1 

Kk 

^^^ 

\ 
\ 

\ 

'^ 

" 

\ 

«^Hk 

i 

1 

r 

? 

N 

Fistula  involving  loss  of  entire  vesicovaginal  septum  as  seen  through  the  speculum. 


During  convalescence  the  urine  should  be  kept  normally  acid,  other- 
wise phosphatic  deposits  may  form  in  the  line  of  union  and  on  the  sutures 
and  prevent  or  destroy  union.  The  benzoic  acid  mixture  or  the  acid 
sodium  phosphate,  already  mentioned,  should  therefore  be  continued. 
The  long  retention  of  the  catheter  and  the  continued  dorsal  position 
may  give  rise  to  great  discomfort;  hence  the  necessity  in  many  cases 
of  using  more  or  less  morphine,  opium,  or  other  anodyne.  A  cathartic 
should  be  given  on  the  third  day,  and  thereafter  the  bowels  kept  regu- 
lar by  moderate  catharsis  and  enemata.  After  the  final  removal  of 
the  catheter  there  may  be  retention  of  urine,  and  it  may  be  necessary, 
therefore,  in  order  to  prevent  distention  of  the  bladder,  to  draw  the  urine 
every  few  hours.    In  old  cases  the  bladder,  either  from  disuse  or  from 


GENITAL  FISTVL.E 


589 


cystitis,  may  be  nuuli  fontracted,  and  therefore  liable  to  distension 
from  a  small  quantity  of  urine.  The  functional  i)o\vcrs  of  the  bladder 
and  urethra  i)ro<:ressively  improves  as  the  bladder  j^radually  becomes 
accustomed  to  the  retention  of  considerable  quantities  of  urine,  so 
that  a  bladder  for  many  years  contracted  by  vesicovaginal  fistula  may 
regain  its  full  capacity'  in  a  short  time  after  closure  of  the  opening. 

Atypical  Operations. — The  ingenuity  and  skill  of  the  operator  will 
enable  him  to  modify  the  operation  according  to  the  requirements  of 
an  at^-pical  case.  An  operation  may  be  only  partially  successful, 
and  may  have  to  be  repeated  again  and  again  until  the  closure  is  com- 
plete, or  it  may  be  necessary  to  close  the  opening  only  in  part  at  each 
one  of  several  operations. 


FicrRE  333 


Anterior  wall  of  cervix  uteri  united  to  the  neck  of  the  bladder.     One  suture  in  place,  but  not  tied. 


Loss  of  the  Entire  Vesicovaginal  Septum  is  associated  usually  with 
more  or  less  destruction  of  cervical  tissue  and  cicatricial  development 
in  the  posterior  vaginal  fornix.  The  usual  operation  in  such  a  case  is 
to  close  by  a  transverse  line  of  union — that  is,  to  stitch  the  anterior 
lip  of  the  cer^-ix  uteri  to  the  neck  of  the  bladder.  In  some  cases  the 
cer\-ix  is  immovable  and  cannot  be  drawn  down  to  the  neck  of  the 
bladder  until  the  post-cerx-ical  cicatrices  have  been  di\-ided  freely  by 
a  deep  transverse  incision  back  of  the  cer\-ix.  In  order  to  gain  the 
required  reach,  it  may  be  permissible  to  split  the  cervix  bilaterally. 


590 


TRAUMATISMS 


Figure  333  shows  the  fistula  closed  by  union  of  the  cervix  uteri  to  the 
neck  of  the  bladder. 

So  much  of  the  anterior  lip  may  have  sloughed  away  that  it  cannot 
be  drawn  down  to  the  neck  of  the  bladder.  In  such  a  case  some  operators 
turn  the  cervix  uteri  into  the  bladder  by  union  of  the  posterior  lip 
of  the  cervix  to  the  neck  of  the  bladder.  This  would  establish  a  com- 
munication between  the  interior  of  the  uterus  and  the  bladder.  Figure 
334.  A  great  risk  from  this  operation  is  in  the  possibility  that  infec- 
tion may  pass  from  the  endometrium  to  all  the  urinary  organs  or  from 
the  bladder  to  the  uterus,  Fallopian  tubes,  and  even  to  the  peritoneum. 
The  chief  danger,  however,  is  that  the  operation  may  form  a  pouch 

Figure  334 


Uterus  turned  into  bladder  to  secure  retention  of  urine.     Posterior  lip  of  cervix  united  to  neck  of 
bladder.     Anterior  lip  of  cervix  sloughed  away.     Uterus  retroverted. 


in  which  urine  will  stagnate,  with  resultant  phosphatic  deposit  and 
incurable  cystitis,  only  to  be  relieved  by  reopening  the  bladder  and 
giving  it  drainage.  See  Artificial  Vesicovaginal  Fistula  for  Cystitis. 
If  the  fistula  be  closed,  so  as  to  avoid  the  formation  of  such  a  pouch, 
cystotomy  may  be  unnecessary;  it  is,  unfortunately,  too  often  impossible 
to  avoid. 

Kolpokleisis,  or  closure  of  the  vagina,  is  an  operation  designed  to 
secure  retention  of  urine  in  cases  of  otherwise  inoperable  vesicovaginal 
fistula.  It  is  performed  by  denuding  a  wide  strip  all  around  the  vaginal 
outlet  just  within  the  vulva  and  uniting  the  denuded  surfaces  upon 
themselves  by  means  of  interrupted  sutures.     The  effect  is  to  make 


GENITAL  FISTVLJE 


591 


one  cavity  of  the  liladder  and  \a,uiiia.  This  oa\lty  receives  the  urine, 
menstrual  blood,  and  uterine  secretions.  The  o])eration  always  leads 
to  inflammation  more  distressing  than  the  condition  for  the  relief 
of  which  it  has  been  invoked.  Emmet,  in  the  strongest  terms,  con- 
demns the  operation  and  urges  that  it  never  be  done  in  any  case.  He 
advises  that  the  parts  be  made  to  heal  with  the  opening  unclosed,  and 
that  the  ])atient  be  kept  as  comfortable  without  an  operation  as  clean- 
liness and  care  can  make  her.  The  stagnant  urine  constantly  present 
in  the  vaginal  pouch  formed  by  the  operation  always  produces  dis- 
tressing— not  to  say  dangerous — disease  of  the  urinary  organs.  In 
this  connection  the  writer  offers  from  his  practice  two  instructive 
cases  :^ 

Figure  335 


The  dotted  lines  indicate  the  parts  destroyed  by  slough.     The  perineum  was  not  destroyed,  but  was 

completely  torn  apart. 

Case  I. — -The  injury  in  this  case,  Figure  335,  was  more  extensive 
than  would  ordinarily  be  repaired  by  plastic  surgery.  The  cervix 
uteri  to  the  level  of  the  internal  os,  the  vesicovaginal  and  urethro- 
vaginal septum,  and  the  rectovaginal  septum  had  sloughed  away 
entirely;  the  perineum  was  completely  lacerated  through  the  sphincter 
ani  muscle.  The  fundus  of  the  inverted,  ulcerated,  and  semi-stran- 
gulated bladder  protruded  through  the  pelvic  outlet;  this  outlet  was 
bounded  by  the  sides  of  the  vulva,  by  the  posterior  and  lateral  margins 
of  the  anus,  and  by  the  pubes.    Thus  all  control  of  both  urethra  and 


'  Operations  in  the  case  of  Mrs.  G.  A.  M.,  at  St.  Luke's  Hospital,  Chicago. 


592  TRA  UMA  TISMS 

anus  was  lost.  The  uterus  was  occluded  by  contracted  cicatricial 
tissue  and  was  full  of  retained  menstrual  fluid. 

Clearly  the  conditions  would  discourage  any  effort  to  repair  by 
ordinary  methods.     The  problem  was  fourfold,  and  as  follows: 

To  reopen  the  closed  uterine  canal  and  release  the  imprisoned  men- 
strual fluid. 

To  replace  the  lost  vesicovaginal  septum. 

To  replace  the  lost  urethrovaginal  septum. 

To  replace  the  lost  rectovaginal  septum. 

To  reunite  the  sphincter  ani  muscle. 

A  free  incision  with  sharp-pointed  scissors  into  the  uterus  reopened 
the  uterine  canal  and  re-established  normal  menstruation. 

The  labia  minora  were  much  hypertrophied,  and  were  therefore 
capable  of  supplying  abundant  material  for  the  replacement  of  the 
lost  vesicovaginal  wall;  to  this  end,  they,  together  with  the  adjacent 
tissue  around  and  below  them,  were  dissected  off  from  above  down- 
ward, but  not  detached  at  their  lower  ends.  An  area  on  each  side 
just  within  the  vulva,  close  to  the  margin  of  the  bladder  mucous  mem- 
brane, was  freshened  by  denudation  and  splitting,  and  the  edge  of 
each  corresponding  labium  was  turned  in  and  stitched  to  this  area 
with  silkworm-gut  sutures.  The  flap  thus  formed  on  the  right  side 
united  perfectly  in  its  transplanted  position;  the  flap  on  the  left  side 
partly  sloughed  away.  The  right  transplanted  labium  now  took  its 
nutrition  through  the  lower  uncut  end  and  the  new  tissues  to  which  it 
was  united.  It  was  not  possible,  however,  at  the  first  transplantation 
to  carry  the  labium  sufficiently  high  to  unite  it  with  the  upper  margin 
of  the  fistula  because  it  would  not  reach  far  enough  to  fill  out  the  space 
left  by  the  sloughed-out  vesicovaginal  septum;  in  order  to  make  it 
reach,  the  transplanting  operation  had  to  be  done  three  times — that  is, 
the  labium  was  turned  end  for  end  upon  itself  three  times,  and  finally 
planted  in  place  of  the  lost  vesicovaginal  wall.  One  face  of  this  labium 
was  now  the  bladder  side,  and  the  other  was  the  vaginal  side  of  the 
restored  vesicovaginal  wall.  In  order  to  maintain  the  nutrition  of  the 
flap  during  the  period  of  its  transplantation  several  months  were  allowed 
to  intervene  between  the  transplanting  operations.  Finally,  after 
numerous  attempts,  in  which  sometimes  a  little  was  gained  and  some- 
times nothing,  the  margins  of  the  flap  were  united  to  the  margins  of 
the  opening  at  every  point  and  the  integrity  of  the  vesicovaginal  septum 
was  restored. 

The  urethra  was  repaired  by  denuding  two  parallel  strips,  three- 
quarters  of  an  inch  apart,  on  either  side  of  the  urethral  site,  and  unit- 
ing them  one  to  the  other  by  interrupted  silkworm-gut  sutures.  This 
formed  a  new  urethrovaginal  wall.  The  remnant  of  the  left  labium 
minus  was  utilized  in  this  part  of  the  work.  The  urethra  thus  formed 
immediately  gave  a  measurable  degree  of  retentive  power  when  the 
woman  was  lying  down.  The  bladder,  however,  was  much  contracted 
from  cystitis,  and,  having  but  small  capacity,  was  at  first  of  necessity 
often  evacuated. 


GENITAL  FISTULA 


593 


The  rectovaginal  septum  was  replaced  by  drawinjii:  down  the  loose 
rectal  wall  from  al)o\e  into  the  ^ap,  and  after  denudation  uniting  it 
to  the  lateral  walls  of  the  vagina  with  fine  buried  catgut  sutures.  At 
the  same  time  thecompletely  ruptured  perineum,  including  the  sphincter 
ani  muscle,  was  reunited.  The  bowel  and  sphincter  muscle  at  once 
resumed  their  normal  functions.  Nineteen  operations  in  all  were 
perft)rmed  before  this  result  was  reached. 

The  patient,  two  years  after  her  discharge  from  the  hospital,  reported 
perfect  control  of  the  bowel  and  practically  perfect  control  of  the 
urethra.  In  a  letter  written  at  that  time  she  said:  "I  ha\e  almost 
perfect  control  of  the  urine  at  all  times;  I  say  almost,  because  of  there 
being  a  slight  weakness  at  times;  but  it  is  not  often,  and  even  then  the 
amount  of  leakage  is  not  great.  I  have  taken  up  the  study  of  short- 
hand, typewriting,  and  telegraphy,  and  if  I  make  a  success  of  it  shall 
feel  that  i\\\  life  has  not  been  a  failure." 


Figure  336 


The  dotted  lines  show  the  parts  which  had  sloughed  out.    Red  hne  shows  remaining  portion  of 

bladder-wall. 


This  case,  a  curiosity  in  surgery,  illustrates  what  may  sometimes 
be  accomplished  by  sustained  effort;  little  by  little,  line  by  line,  in 
the  face  of  one  discouragement  after  another,  the  work  was  done. 
The  treatment  continued  over  a  period  of  more  than  two  years,  with 
an  intermittent  period  of  three  years,  when  nothing  was  done.  INIost 
of  the  time  it  seemed  like  following  the  forlorn  hope;  now  total  failure, 
now  a  little  success,  until,  finally,  nineteen  operations  under  ansesthesia 
had  been  done.     ^Yords  fail  to  describe   the  bravery  and   patience 


594 


TRAUMATISMS 


displayed  by  this  woman,  or  the  difficulties  and  discouragements  which 
the  surgeon  must  meet  in  such  a  case. 

Case  II} — The  entire  vesicovaginal  septum,  the  vaginal  portion 
of  the  cervix,  and  the  anterior  wall  of  the  cervix  to  the  internal  os 
had  sloughed  away,  leaving  no  bladder  tissue  between  the  inner 
extremity  of  the  urethra  and  a  point  corresponding  to  the  plane  of  the 
internal  os  uteri.  See  Figure  336.  The  upper  and  lower  fragments 
of  the  opening  could  not  be  approximated — that  is,  the  anterior  wall 
of  the  uterus  could  not  be  approximated  to  the  neck  of  the  bladder 
after  the  method  shown  in  Figure  333.  The  only  operation  which  at 
first  seemed  possible  was  to  unite  the  posterior  wall  of  the  cervix  uteri 

Figure  337 


Section  at  X  Z  shows  the  fundus  of  the  bladder  stitched  to  the  neck  of  the  bladder. 


to  the  neck  of  the  bladder,  as  shown  in  Figure  334.  This  would  have 
turned  the  cervix  uteri  into  the  bladder,  and  menstruation  would  have 
taken  place  through  the  urethra.  But  while  this  was  under  considera- 
tion it  was  found,  on  further  examination,  that  the  mucous  membrane 
of  the  bladder,  if  caught  with  the  tenaculum  about  an  inch  in  front 
of  the  uterus,  could  be  drawn  to  the  neck  of  the  bladder — that  is,  to 
the  lower  margin  of  the  fistula — and  held  there  without  undue  traction. 
A  strip  of  mucous  membrane  across  the  bladder  was  therefore  denuded 
from  side  to  side  an  inch  in  front  of  the  uterus.  This  denudation  was 
continued  around  the  lateral  and  lower  margins  of  the  fistula.     The 

1  E.  C.  Dudley.     Journal  of  the  American  Medical  Association,  March  27,  1886. 


CE.YITAL   FTSTI'L.E 


595 


strip  of  (loniuled  surface  across  tlie  bladder  was  then  drawn  down  and 
stitched  to  the  lower  margin  of  the  fistula  X  Z,  Figure  3'^7.  Thus 
the  bladder  was  divided  into  two  parts,  the  upper  closed  part  communi- 
cating with  the  urethra  and  receiving  the  urine  from  the  ureters;  the 
lower  ojxMi  part  rei)lacing  the  lost  anterior  \'aginal  wall.  In  other  words, 
the  part  of  the  bhukler-wall,  situated  between  the  line  of  denudation 


FiQUUE  338 


Shows  act  of  splitting  margins  of  fistula  preparatorj-  to  approximating  the  fragments  of  the  vesical 
plate  of  the  vesicovaginal  wall.     Latcroprone  position  and  Sims'  speculum. 

across  the  fundus  of  the  bladder  and  the  uterus,  was  utihzed  as  a  sub- 
stitute for  the  lost  vesicovaginal  septum  and  anterior  wall  of  the  cervix. 
Twenty-two  sutures  were  used.  Notwithstanding  the  failure  of  the 
nurse  on  the  third  day  to  keep  the  catheter  in  place,  and  the  consequent 
accumulation  of  several  ounces  of  urine  in  the  bladder,  union  by  first 
intention  was  complete.    The  bladder,  although  reduced  in  size  by  the 


596 


TRAUMATISMS 


operation,  has  normally  performed  its  functions  ever  since.  It  is  large 
enough  to  enable  the  woman  to  retain  her  urine  all  night.  The  writer 
is  not  aware  that  another  similar  operation  has  been  recorded. 

Howard  Kelly  suggests  a  plan  which  might  be  adopted  to  advan- 
tage in  place  of  the  one  just  described.  It  is  to  dissect  the  bladder 
entirely  free  from  the  uterus,  so  as  to  make  a  wide  opening  between 

Figure  339 


Fistula  being  closed  by  union  of  vesical  plate  of  the  vesicovaginal  wall;  this  leaves  the  vaginal  plate 

still  open.     Latere. 


the  vagina  and  the  peritoneum — that  is,  to  make  an  anterior  vaginal 
section  into  the  peritoneal  cavity.  The  bladder-wall,  anterior  to  the 
uterus,  thus  freed  from  its  uterine  attachments,  may  then  be  drawn 
down  so  as  to  close  the  fistula  by  a  transverse  line  of  sutures.  Since 
the  bladder-wall  is  covered  with  peritoneum,  and  since  peritoneal  sur- 
faces are  very  prone  to  unite  readily,  such  an  operation  w^ould  be  very 


GEMTAL  risri'L.^  597 

apt  to  succeed.    After  closure  of  the  fistula  the  wound  anterior  t(j  the 
uterus  sliould  l)e  closed. 

Another  possible  method,  su^j^estcd  l)\  Mackenrodt,'  for  such  cases 
is  to  detach  the  vesical  from  the  \a^inal  plate  of  the  vesicovaji^inal 
wall  and  to  close  the  fistula  by  suturing  to(i;ether  the  vesical  plate 
independently,  leaving  the  vaginal  plate  open  to  heal  by  granulation. 
Figures  33S  and  339. 

VESICO-UTERINE  FISTULA 

This  form  of  fistula  has  been  mentioned  in  the  chapter  on  Lacera- 
tion of  the  Cervix;  it  is  the  result  of  anterior  laceration  of  the  cervix 
extending  into  the  bladder.  Usually  the  effort  of  nature  to  repair 
produces  union  in  the  lower  part  of  the  laceration  so  as  to  repair  the 
whole  vaginal  part  of  the  injury  and  to  leave  the  uterine  part  open. 
Figure  295  shows  the  sinus  extending  from  the  bladder  to  the  interior 
of  the  uterus. 

The  Diagnosis  and  Treatment  of  Vesico-uterine  Fistula 

The  diagnosis  is  based  upon  the  history  of  the  case  and  the  passage 
of  urine  through  the  os  externum.  The  treatment  is  to  reproduce  the 
original  tear  by  an  incision  through  the  anterior  lip  of  the  cervix 
directly  into  the  sinus.  The  fistula  thus  exposed  at  the  angle  of  the 
incision  is  denuded,  and  the  whole  wound,  including  the  fistula  and 
the  cervical  laceration,  is  closed  with  silk^'orm-gut  sutures.  Except 
that  the  sutures,  in  addition  to  closing  the  cervix,  are  made  also  to 
close  the  opening  into  the  bladder,  the  operation  does  not  differ  from 
the  ordinary  operation  for  closure  of  an  anterior  laceration  of  the  cervix 
uteri.- 

URETHROVAGINAL  nSTULA 

This  form  of  fistula  may  be  made  intentionally  by  a  surgical  opera- 
tion in  the  treatment  of  urethritis  and  other  diseases  of  the  urethra; 
it  is  occasionally  the  result  of  ulcerative  processes.  If  the  neck  of  the 
bladder  is  not  involved,  the  functional  power  of  the  urethra  to  retain 
urine  may  be  unimpaired.  The  operation  for  closure  is  the  same  as 
that  described  for  vesicovaginal  fistula.  The  after-treatment  consists 
of  the  hot-water  douche  t'^'ice  daily.  The  self-retaining  catheter  is  not 
required.  Ordinary  catheterization  is  permissible,  but  if  the  woman 
can  pass  urine  without  help,  it  is  not  required. 

URETEROVAGINAL  nSTULA 

Uretero vaginal  fistula  may  be: 

I.  Congenital;  one  or  both  ureters  may  open  into  the  vagina. 
II.  Acquired. 

1  Centralblatt  fur  Gyniikologie,  1S94,  Xo.  8;  from  Kelly. 

~  Emmet.     Principles  and  Practice  of  Gynecology,  second  edition,  p.  63.5. 


598  TRA  UMA  TISMS 

Causes  of  Ureterovaginal  Fistula 

The  causes  of  acquired  ureterovaginal  fistula  are : 

1.  Sloughing,  due  to  pressure-necrosis  during  labor. 

2.  Necrotic  processes,  due  to  malignant  or  specific  disease. 

3.  Traumatisms,  usually  surgical. 

Diagnosis  of  Ureterovaginal  Fistula 

The  diagnosis  is  made  by  passing  a  ureteral  catheter  into  the  ureter 
at  the  point  whence  the  urine  escapes.  In  the  congenital  form  the 
ureter  opens  directly  into  the  vagina  and  has  no  communication  between 
the  ureter  and  the  bladder.  The  acquired  form  may  or  may  not  be 
associated  with  a  vesicovaginal  fistula.  If  so  .associated,  the  ureteral 
opening  is  usually  in  the  margin  of  this  fistula.  Such  a  combination  is 
called  uretero-vesicovaginal  fistula.  In  unilateral  ureterovaginal  fistula, 
the  urine  from  one  kidney  only  vdll  escape  through  the  vagina;  that 
from  the  other  will  pass  naturally  through  the  urethra.  If  the  defect 
is  bilateral,  both  ureters  will  open  into  the  vagina.  In  unilateral 
ureterovaginal  fistula  colored  fluid  may  be  introduced  into  the  bladder 
and  retained  there  while  the  colorless  urine  will  escape  from  the  ureter 
directly  through  the  vagina. 

Treatment  of  Ureterovaginal  Fistula 

The  treatment  of  a  ureterovaginal  fistula  is  as  follows:  First,  split 
the  ureterovesical  wall  for  a  little  distance  back  from  the  margin  of 
the  vesical  opening.  This  makes  a  new  and  larger  opening  for  the 
ureter  into  the  bladder  remote  from  and  out  of  the  way  of  the  vesico- 
vaginal fistula.    The  latter  may  then  be  closed  in  the  usual  manner. 

If  the  ureterovaginal  fistula  is  not  associated  with  a  vesical  opening 
it  should  be  converted  into  a  uretero-vesicovaginal  fistula  by  an  incision 
at  the  ureterovaginal  outlet  directly  through  into  the  bladder.  The 
operation  then  is  continued  as  described  above  for  a  uretero-vesico- 
vaginal fistula. 

Dudley  Clamp  Operation. — I  present  herewith  the  report  of  a  unique 
case  in  which  stricture  of  the  ureter  was  a  possible  result  of  laceration 
of  the  cervix  uteri  and  ureterovaginal  fistula  a  result  of  trachelorrhaphy.^ 

In  this  case  a  left  ureterovaginal  fistula  occurred  three  days  after 
introducing  some  rather  deep  sutures  for  the  control  of  secondary  hem- 
orrhage following  trachelorrhaphy.  About  one-half  of  the  urine  escaped 
from  the  left  ureter  into  the  vagina;  the  remainder  passed  naturally 
through  the  urethra.  The  ureteral  bougie  passed  through  a  Nitze- 
cystoscope  demonstrated  a  tight  stricture — possibly  obliteration  of 
the  ureter  near  the  opening  of  the  fistula  and  between  this  opening 
and  the  ureteral  orifice  in  the  bladder. 

1  Boston  Medical  and  Surgical  Journal,  vol.  cxlii,  No.  9. 


GENITAL  FISTULA  599 

About  four  weeks  after  the  accident,  vith  the  purpose  of  perform- 
injj  some  operation  to  rc-cstahlish  a  free  communication  l)et\vcen  the 
injnred  nrctcr  and  the  bhidder,  1  etherized  the  patient,  and  for  more 
than  three-(iuarters  of  an  hour  with  uterine  tenacnhi  and  a  fine  probe 
sought  in  vain  for  the  point  where  the  ureter  opened  into  the  vagina. 
No  urine  came  through  to  mark  this  point,  and  even  after  some  rather 
extensive  (hssection  with  the  scissors  I  was  unable  to  locate  the  fistula, 
nor  was  I  able  to  make  out  the  ureter  by  palpation.  Finally,  however, 
a  little  spurt  of  urine  appeared  just  to  the  left  of  the  cervix  uteri,  but 
I  was  unable  at  this  point  to  pass  even  a  very  fine  probe.  Each  attempt 
only  resulted  in  the  making  of  a  false  passage — a  thing  difficult  to 
avoid  under  such  conditions.  I  then  made  a  colpocystotomy,  cutting 
witii  the  scissors  through  the  vesicovaginal  wall  in  the  median  line  and 
in  the  long  axis  of  the  vagina  just  in  front  of  the  cervix.  The  vesico- 
vaginal fistula  thus  made  was  an  inch  long.  The  upper  extremity  of 
it  terminated  close  to  the  anterior  wall  of  the  cervix  uteri.  With  a  pair 
of  straight  scissors  I  then  extended  the  incision  upward,  and  to  the  left 
as  nearly  as  could  be  estimated,  to  the  point  whence  the  u^^ine  had 
escaped.  The  object  was  if  possible  to  convert  the  uretero vaginal 
fistula  into  a  uretero- vesicovaginal  fistula;  so  that  the  ^ireter  should 
open,  not  into  the  vagina,  but  into  the  margin  of  a  vesicovaginal  fistula. 
After  another  long  search  I  again  failed  to  find  the  fistulous  opening 
into  the  ureter,  until  it  was  located  by  another  spiut  of  urine,  but 
since  the  opening  was  too  small  to  admit  a  fine  probe,  it  could  not  be 
entered.  I  then  still  further  enlarged  the  vesicovaginal  fistula  in  a 
direction  to  the  left  of  the  uterus,  and  by  good  fortune  opened  into 
a  very  much  dilated  ureter,  from  which  immediately  there  gushed 
two  or  three  ounces  of  pent-up  urine.  A  ureteral  bougie  was  now  passed 
without  obstruction  to  the  kidney. 

The  situation  now  being  much  simplified,  the  follo"^dng  procedures 
were  adopted :  The  bladder  mucosa  was  stitched  to  the  vaginal  mucosa 
all  around  the  artificial  vesicovaginal  fistula.  In  this  way  the  exposed 
surfaces  were  covered  and  hemorrhage  controlled.  A  haemostatic 
forceps,  with  handles  about  four  inches  long  and  with  slender  jaws 
about  an  inch  long,  was  passed  through  the  vesicovaginal  fistula. 
Figure  340.  The  forcep  jaws  were  then  passed,  one  into  the  ureter 
and  the  other  into  the  bladder,  so  that  the  forceps  when  locked  included 
in  their  bite,  lu-eteral  wall,  bladder-wall,  and  the  connective  tissue 
between.  In  this  way  the  lower  extremity  of  the  cut-off  ureter  was 
clamped  into  close  relations  with  the  bladder.  The  expectation  was 
that  the  structures  within  the  bite  of  the  forceps  would  be  destroyed 
by  pressure-necrosis,  and  that  a  wide,  free,  ureterovesical  opening 
would  be  established  at  a  point  somewhat  distant  from  the  artificial 
opening  into  the  bladder,  and  that  in  this  way  the  case  would  become 
one  of  uncomplicated  vesicovaginal  fistula.  The  forceps  came  off 
in  about  three  days,  and  twelve  days  later  the  vesicovaginal  fistula 
was  closed  by  suture  in  the  ordinary  way.  At  the  time  of  this  operation 
the  new  ureteral  orifice  was  found  to  be  perfectly  open  and  very  patulous. 


600 


TRAUMATISMS 


The  subsequent  history  was  uncomplicated,  union  was  complete,  and 
in  a  short  time  the  patient  was  discharged  cured.  In  a  letter  written 
about  six  months  after  the  final  operation  the  patient  reported  entire 
freedom  from  pain  in  the  left  inguinal  region  from  which  she  had 
suffered,  and  which  had  made  her  a  semi-invalid  for  twenty  years. 


Figure  340 


CORPUS 

UTER 


Author's  operation  for  ureterovaginal  fistula.' 


In  the  case  just  reported  the  distance  and  amount  of  tissue  between 
the  bladder  and  ureter  was  so  great  that  it  could  hardly  have  been 
divided  with  the  scissors  without  danger  of  uncontrollable  hemorrhage 
or  of  the  exposure  of  broad  surfaces  to  reunite,  or  to  cicatrize  and  con- 
tract. These  difficulties  were  obviated  by  clamping  the  ureter  into 
close  contact  with  the  bladder,  so  that  when  the  forceps  came  off, 
the  exposed  surfaces  left  by  the  necrosis  would,  owing  to  the  compres- 
sion, be  of  small  extent.  The  compression-forceps  used  in  this  way, 
therefore,  may  make  the  operation  practicable  in  those  regions  where 
the  tissue  between  the  ureter  and  the  bladder  is  too  abundant  to  be 
divided  safely  by  scissors. 

It  is  hoped  that  this  operation  will  give  great  security  against  sub- 
sequent stricture  at  the  new  ureteral  orifice — a  security  not  obtainable 
by  any  of  the  usual  procedures. 

Traumatic  ureterovaginal  fistula  as  a  result  of  trachelorrhaphy  is 

1  At  the  present  writing,  March,  1913,  I  have  performed  this  operation  in  numerous  cases,  and  always 
so  far  as  I  have  been  able  to  follow  them,  the  results  have  been  permanently  successful.  In  one  case 
there  was  bilateral  ureterovaginal  fistula,  the  result  of  hysteromyomectomy. 


GENITAL  FISTUL/E  OOl 

rare,  but  as  a  result  of  vaf^iiuil  hysterectomy  aud  other  vaginal  sections 
is  not  of  infreciuont  occurrence.  The  operation  above  (lescril)e(l  is 
applicable  to  the  condition,  whatever  the  cause,  whether  traumatic 
or  congenital. 

The  alternatives  to  the  operation  are  well  known,  and  need  not  be 
described.  To  open  the  abdomen,  sever  the  ureter  and  insert  it  into 
the  bladder-wall  is  an  operation  of  great  difficulty  and  danger,  and 
sometimes  is  of  only  transient  value.  The  same  may  be  said  of  dis- 
secting or  stripping  the  bladder  from  the  pelvic  wall,  finding  the  ureter 
and  inserting  it  into  the  bladder,  without  invading  the  peritoneal 
cavity.  The  utilization  of  the  vaginal  mucosa  in  a  plastic  operation 
for  the  purpose  of  diverting  the  urine  from  the  vagina  to  the  bladder 
usually  results  in  failure  of  union,  or,  later,  in  cicatricial  contraction 
and  consequent  stricture  of  the  ureteral  orifice.  The  operation  of 
switching  the  ureter  into  the  intestine  or  into  the  opposite  ureter  is  of 
very  questionable  propriety. 

As  a  corollary  to  the  case  just  described,  the  following  observation, 
if  well  founded,  may  prove  to  have  practical  significance.  It  is  probable 
in  this  case  that  the  laceration  having  extended  into  the  parametria 
had  torn  the  structures  around  the  ureter.  There  may  also  have  been 
injurious  pressure  by  the  presenting  part  of  the  child  against  the  ureter. 
Such  lacerated  tissues  would  necessarily  heal  by  cicatrization  and 
contraction,  and  the  cicatrix  thus  formed  would  draw  the  bruised 
ureter  toward  the  uterus,  compress  it,  and  so  give  rise  to  obstruction 
both  from  stricture  and  from  kinking.  Contracting  cicatricial  tissue 
extending  from  the  cervix  around  the  ureter  would  necessarily  draw 
the  ureter  into  closer  proximity  to  the  uterus,  where  a  deep  suture 
applied  for  closure  of  the  cervix  or  to  control  bleeding*would  be  apt 
to  wound  it,  or  by  compression  cause  a  narrowing  of  the  lumen  of  that 
part  lying  within  its  grasp.  In  the  case  described  the  stricture  extended 
at  least  a  half-inch  on  either  side  of  the  ureteral  fistula.  It  was  evi- 
dently this  constricted  portion  of  the  ureter  that  was  caught  by  the 
needle  and  cut  off  or  penetrated  by  the  suture. 

It  would  be  quite  impossible,  without  further  observation,  to  esti- 
mate the  proportion  of  cases  in  which  laceration  of  the  cervix  uteri 
causes  stricture  or  kinking  of  the  ureter.  Every  gynecologist  may  revert 
to  a  class  of  cases,  not  small,  in  which  there  is  extensive  laceration 
of  the  cervix  uteri  on  one  or  both  sides,  and  in  which  the  localized  pain 
dating  from  the  puerperium  is  not  readily  accounted  for  by  palpable 
lesions,  and  is  not  relieved  in  the  slightest  degree  by  the  repair  of  the 
cervix.  As  I  look  back  over  a  long  experience  I  recall  many  such  cases, 
and  among  them  the  one  just  reported. 

But  W'hy,  one  may  ask,  if  the  ureter  is  often  drawn  by  cicatricial 
contraction  close  to  the  uterus,  is  it  not  more  frequently  injured  by 
operations  on  the  cervix?  The  answer  is  that  if  the  sutures  of  trach- 
elorrhaphy were  not  usually  introduced  close  to  the  uterus  or  very 
superficially  in  the  vaginal  wall,  more  cases  of  uretero vaginal  fistula 
probably  would  be  reported.  This  case  was  very  hemorrhagic,  and 
37 


602  TRAUMATISMS 

therefore  required  exceptionally  deep  sutures  to  control  the  bleeding. 
In  view  of  the  facts  already  set  forth,  I  desire  to  submit  two  questions, 
as  follows: 

Question  1,  In  all  cases  of  extensive  laceration  of  the  cervix  uteri, 
in  which  the  localized  pain  is  not  accounted  for  by  palpable  lesions, 
should  we  not  pass  a  series  of  graduated  ureteral  bougies  on  the  side 
corresponding  to  the  laceration?  This  would  be  for  the  purpose  of 
measuring  the  caliber  of  the  ureter  and  of  locating  a  possible  stricture. 
The  principles  of  examination  would  be  similar  to  those  of  measuring 
the  caliber  of  the  male  urethra  in  the  diagnosis  of  stricture. 

Question  2.  In  a  case  of  ureteral  stricture  due  to  laceration  of  the 
cervix  uteri,  or  to  any  other  cause,  and  situated  wdthin  the  range  of 
a  vaginal  operation,  would  not  the  surgeon  be  warranted  in  opening 
the  bladder  and  then  proceeding,  as  in  the  case  reported,  to  establish 
a  new  ureteral  orifice?  In  otlrer  words,  should  not  that  condition  which 
in  this  case  w^as  the  result  of  an  accident,  be  reproduced  deliberately 
in  similar  cases? 

My  answer  to  these  questions  would  be  in  the  affirmative. 

Dr.  Edward  Reynolds^  has  reported  a  successful  case  of  a  clamp 
operation  by  the  method  above  described.  Cystoscopic  examination 
after  the  recovery  of  the  patient  show^ed  a  ureteral  orifice  which,  except 
the  high  location,  presented  all  the  appearance  of  the  natural  orifice. 

Accidental  Wounding  of  the  Ureter  in  Vaginal  Hysterectomy. — On  April 
22,  1903,  I  performed  vaginal  hysterectomy  for  carcinoma  of  the  corpus 
uteri  upon  a  woman,  seventy  years  of  age,  a  patient  of  Dr.  Lord,  of 
Piano,  Illinois,  whose  pelvic  organs  long  since  had  passed  into  extreme 
senile  atrophy.  In  making  the  opening  into  the  peritoneal  cavity 
between  the  bladder  and  the  uterus  the  carcinomatous  disease  had 
extended  so  far  anteriorly  that  the  bladder  was  opened  immediately 
in  front  of  the  cervix  uteri.  An  opening  into  the  peritoneum  posterior 
to  the  uterus  was  made  without  accident,  the  broad  ligaments  then 
were  isolated  and  cut  close  to  the  uterus  and  the  uterus  removed. 
After  cutting  through  the  right  broad  ligament  a  spurt  of  fluid  was 
observed,  which  upon  examination  proved  to  have  come  from  the  right 
ureter,  showing  that  the  ureter  had  been  divided.  This  accident  to 
the  ureter  was  consequent  upon  the  fact  that  the  cicatricial  tissue  of  an 
old  cervical  laceration  had  caught  it  and  drawn  it  into  close  relation 
with  the  uterus  into  the  line  of  incision.     Figure  341. 

After  a  hasty  consultation  with  Dr.  Kolischer,  w^ho  chanced  to  be 
present,  it  was  decided,  if  possible,  to  establish  a  direct  communica- 
tion between  the  upper  cut  end  of  the  ureter  and  the  interior  of  the 
bladder.  The  usual  method 'of  performing  this  operation  is  to  make 
an  opening  into  the  bladder,  push  the  end  of  the  ureter  through,  and 
fasten  it  there  by  means  of  sutures.  Appreciating  the  well-known 
tendency  of  the  cut  end  of  the  ureter  to  contract  when  introduced 
into  the  bladder  in  this  way,  and  having  at  hand  a  vesicovaginal  fistula 

1  Boston  Medical  and  Surgical  Journal,  January  24,  1901. 


GENITAL   FISm.'E 


G03 


which  rendered  (lie  interior  of  tlie  hhidder  ([iiite  accessible,  I  made 
use  of  a  method  which,  so  i'ar  as  I  know,  had  not  heen  described.  With 
a  K)n<;'  slender  forceps  I  puncturexl  the  bladder  wall  from  within  out- 
ward at  the  point  nearest  to  the  cut  end  of  the  ureter.  Then  after  split- 
tinji;  the  cut  end  of  the  ureter  and  denudint;  the  bladder  mucosa  on 


Finriti;  .'U  1 


FifiiKE  :512 


Figure  341. — Ureter  accidentally  cut  in  vaginal  hysterectomy.  The  upper  cut  end  leads  from 
the  kidney,  the  lower  end  to  the  bladder.     Semi-diagrammatic. 

Figure  342. — The  upper  cut  end  of  the  ureter  split  and  in  the  grasp  of  a  forceps  which  has 
previously  made  an  opening  from  the  interior  to  the  exterior  of  the  bladder  by  puncture.  Semi- 
diagrammatic. 

Figure  343. — The  split  end  of  the  ureter  has  been  drawn  into  the  bladder  by  means  of  the  forceps. 
Semi-diagrammatic. 

Figure  344. — The  split  end  of  the  ureter  having  been  drawn  into  the  bladder  and  the  bladder 
mucosa  having  been  denuded  on  either  side  of  the  opening,  the  two  flaps  are  fastened  to  the  denuded 
mucosa  by  means  of  sutures,  three  on  each  side. 


either  side  of  the  punctured  opening,  I  drew  the  ureter  into  the  bladder, 
Figures  342  and  343,  and  stitched  it  there  by  means  of  fine  chromic 
catgut  sutures.  Figure  344.  By  this  means  the  split  end  of  the  ureter 
was  held  widely  apart  by  means  of  sutures,  so  that  it  could  not  easily 
contract  and  form  a  stricture.  The  tightly  fitting  ureter  made  the 
punctured  bladder  wound  water-tight. 


604  TRAUMATISMS 

The  vesicovaginal  fistula  was  closed  immediately  by  drawing  the 
anterior  margin  of  the  peritoneum  down  to  the  lower  margin  of  the 
vaginal  wound  and  fastening  it  there  with  a  continuous  chromic  catgut 
suture.  In  like  manner  the  posterior  margin  of  the  peritoneum  was 
brought  into  contact  with  the  vaginal  margin  of  the  wound,  after 
which  the  wound  from  the  peritoneal  cavity  into  the  vagina  was  closed 
in  the  usual  way,  the  stumps  of  the  broad  ligaments  being  drawn 
down  into  the  vagina  and  fastened  there  by  means  of  sutures,  one  at 
each  end  of  the  vaginal  wound.  During  the  two  weeks  following  the 
operation  the  bladder  was  kept  empty  by  the  continuous  use  of  a  self- 
retaining  catheter. 

Cystoscopy  by  Dr.  Kolischer  and  myself  four  weeks  later  showed 
a  perfectly  patulous  opening  of  the  ureter,  the  divided  flaps  of  which 
were  united  firmly  to  the  bladder  mucosa. 

The  special  advantages  of  the  method,  as  already  pointed  out,  are 
twofold:  1.  A  water-tight  wound  around  the  ureter  where  it  enters 
the  bladder.  2.  Security  against  contraction  of  the  end  of  the  ureter 
where  it  enters  the  bladder.  These  advantages  would  lead  me  to  repeat 
the  operation  if  the  bladder  happened  to  be  open;  I  would  make  an 
artificial  vesicovaginal  fistula  for  this  purpose  if  the  bladder  were  not 
open. 

RECTOVAGINAL    FISTULA 


Causes  of  Rectovaginal  Fistula 

Parturition,  although  a  frequent  cause,  is  relatively  at  least  a  less 
frequent  cause  of  rectovaginal  than  of  vesicovaginal  fistula;  the  lesion 
is  observed  more  commonly  as  the  result  of  sj'philis  or  cancer.  Occa- 
sionally a  peri-anal  abscess  is  situated  in  the  perineum,  and  in  the  acute 
stage  breaks  into  both  the  vagina  and  the  lower  bowel;  or,  later,  the 
perineum  may  be  perforated  from  the  anus  to  the  vagina  by  the 
burrowing  of  pus.    Such  cases  are  apt  to  be  sj-philitic  or  tuberculous. 

Diagnosis  of  Rectovaginal  Fistula 

The  diagnosis  is  made  by  digital  or  speculum  examination  by  the 
probe,  or  by  injecting  milk  into  the  rectum  and  observing  the  point 
at  which  it  appears  in  the  vagina. 

Prognosis  of  Rectovaginal  Fistula 

The  lesion,  when  due  to  cancer,  is  incurable;  when  the  cause  is 
syphilis,  the  operation  for  closure,  unless  preceded  by  adequate  specific 
treatment,  usually  fails.  A  sinus  of  tubercular  or  other  inflammatory 
origin  should  be  successfully  closed  by  suture;  but  the  prognosis  is 
much  improved  by  such  preliminary  treatment  as  will  improve  the 


GEXITAL  FISTULA  605 

general  nutrition.  In  fistula  due  to  pressure-necrosis  the  operation 
of  closure  by  suture,  althouj^h  beset  by  more  unfavorable  conditions 
than  in  urinary  fistuhe,  usually  succeeds. 

Operation  for  Rectovaginal  Fistula 

The  principles  are  the  same  as  for  urinary  fistula;.  The  prepara- 
tion is  the  same  as  for  closure  of  the  completely  lacerated  perineum — 
that  is,  free  catharsis  during  several  days  before  the  operation,  and 
the  use  of  such  food  and  intestinal  antiseptics  as  will  reduce  to  the 
minimum  the  amount  of  gas  and  other  contents  of  the  bowel;  much 
depends  upon  making  the  bowel  as  nearly  as  possible  aseptic. 

The  operation  often  fails  from  the  pressure  of  gas  and  other  rectal 
contents  against  the  newly  united  wound;  hence  in  order  to  give, 
during  the  healing  process,  a  free  outlet  for  the  rectum,  the  sphincter 
ani  muscle  should  be  stretched. 

The  denudation  and  passage  of  sutures  should  be  on  the  vaginal  side 
of  the  rectovaginal  wall,  and  should  extend  to  but  not  into  the  rectal 
mucosa.  The  object  is  to  make  the  operation,  so  far  as  possible,  in 
the  more  favorable  soil  of  the  vagina.  In  order  to  insure  thorough 
denudation  of  the  whole  sinus  clear  to  the  margins  of  intestinal  mucosa, 
the  index-finger  of  the  left  hand  in  the  bowel  is  made  to  roll  the  rectal 
margin  toward  the  vaginal  opening,  and  thereby  render  it  accessible 
for  denudation  by  means  of  properly  curved  scissors.  In  a  very  small 
fistula  the  sinus  may  be  inaccessible  for  denudation  until  it  has  been 
made  so  by  free  incision  on  the  vaginal  side.  Such  incision  should  not 
extend  into  the  rectum.  As  in  urinary  fistul^e,  broad  surfaces  for  union 
should  be  denuded  on  the  vaginal  wall.  The  method  of  suture  is  the 
same  as  for  vesicovaginal  fistula. 


ANOVAGINAL    HSTULA 

The  causes,  diagnosis,  and  prognosis  are  much  the  same  as  given 
above  for  rectovaginal  fistula.  The  sinus  runs  through  the  perineum, 
and  may,  therefore,  be  inaccessible  for  denudation,  in  which  case  it 
should  be  laid  open  by  an  incision  on  the  vaginal  side  of  the  perineum, 
but  not  necessarily  through  the  whole  sphincter  ani  muscle.  Most 
operators,  however,  di\-ide  the  entire  perineum  between  the  sinus  and 
the  cutaneous  side  of  the  perineum.  The  remaining  steps  of  the  opera- 
tion then  are  to  denude  freely  and  deeply  the  now  exposed  walls  of  the 
sinus,  and  then  to  close  the  wound  as  in  the  operation  for  complete 
laceration  of  the  perineum.  The  advantage  of  complete  di\'ision  lies 
in  the  immobilization  of  the  sphincter  ani  muscle,  for  unless  severed, 
this  muscle  may,  by  continuous  relaxation  and  contraction,  imperil 
union.  Entire  division  of  the  muscle  or  division  of  all  but  a  few  fibres 
of  it  is  preferable  to  di\Tilsion.  The  after-treatment  of  the  operation 
for  closure  of  the  fistula  is  the  same  as  for  complete  perineorrhaphy. 


PART  V 

DISPLACEMENTS  OP  THE  UTERUS  AND 
OTHER  PELVIC  ORGANS 


CHAPTER  XXXVIII 
DISPLACEMENTS  OF  THE  UTERUS 

General  Considerations 

The  title  of  this  chapter  is  not  to  be  taken  in  a  restricted  sense, 
for  the  uterus  is  anatomically  so  connected  with  adjacent  organs  that 
the  displacements  of  it  cannot  be  considered  intelligently  nor  pre- 
sented satisfactorily  without  at  the  same  time  incidentally  taking  into 
account  the  displacement — causative,  resultant,  and  concmrent — of  the 
ovaries,  Fallopian  tubes,  rectum,  vagina,  bladder,  and  perineum. 

The  following  pathological  sequence  will  serve  as  an  example:  The 
vaginal  outlet  may  be  so  injm-ed  in  labor  as  to  cause  displacement  of 
the  perineum  backward  toward  the  coccyx,  where  it  can  no  longer 
serve  as  a  bulwark  against  the  downward  force  wliich  is  exerted  in  the 
expulsion  of  the  contents  of  the  bladder  and  rectum.  The  force  of 
straining  at  stool  and  of  urination  is  now  exerted  against  the  less 
resisting  bladder  and  rectal  walls;  they  consequently  pouch  into  the 
vaginal  outlet.  The  downward  displacements  thereby  produced  are 
called  cystocele  and  rectocele.  The  vaginal  walls  are  attached  to 
the  uterus,  and,  being  displaced  downward,  must,  by  traction,  pull 
that  organ  to  a  lower  level.  The  uterus  in  turn  is  connected  with  the 
bladder,  rectum,  Fallopian  tubes,  and  ovaries,  and  in  its  own  descent 
draws  these  organs  out  of  place  and  disturbs  their  relation  to  one 
another.  This  shows  how  a  uterine  displacement  may  be  both  causa- 
tive and  resultant.  Concurrent  displacement  of  the  uterus  and  other 
pelvic  organs  may  result,  for  example,  from  the  downward  pressure  of 
a  tumor  or  from  inflammatory  causes. 

It  is  convenient,  because  conformable  to  usage,  to  treat  the  sub- 
ject of  displacements  of  the  pelvic  organs  under  the  heading  Uterine 
Displacements.  At  the  same  time  it  must  be  held  clearly  in  mind 
that  a  uterine  deviation  may  not  be  the  essential  factor  in  the  morbid 
sequence;  on  the  contrary,  it  may,  as  already  stated,  be  only  an  incident. 

(607) 


608 


DISPLACEMENTS 


The  subject,  therefore,  properly  includes  the  displacements  not  merely 
of  the  uterus,  but  of  all  the  pelvic  organs.  It  further  embraces  the 
relations  which  these  displacements  may  bear  to  one  another,  and 
to  such  associated  lesions  as  inflammation,  tumors,  traumatisms,  and 
congenital  defects. 

The  importance  of  a  distinction  between  location  and  position  will 
become  apparent  hereafter:  by  the  former,  is  meant  the  situation  of 
the  organ  regardless  of  its  attitude;  by  the  latter,  is  meant  the  attitude 
alone.  To  change  an  object  from  one  place  to  another,  is  to  change 
its  location;  to  turn  it  over  or  bend  it  upon  itself,  is  to  change  its 
position. 

Normal  Position  of  the  Uterus 

In  many  works  on  anatomy  and  gynecology  the  uterus  is  repre- 
sented as  having  a  straight  or  nearly  straight  canal — as  lying  about 
midway  between  the  symphysis  pubis  and  the  hollow  of  the  sacrum, 

Figure  345 


Classical  representation  of  the  pelvic  organs. 


its  axis  corresponding  with  that  of  the  pelvic  inlet.  The  position  being 
one  of  slight,  and  only  slight,  anteversion  and  anteflexion,  many 
authorities  would  pronounce  the  organ  anteverted  or  anteflexed  to  a 
degree  that  would  endanger  health  if  by  digital  examination  its  anterior 
wall  could  be  felt  through  the  anterior  wall  of  the  vagina.    This  classical 


DISPLACEMENTS  OF  THE  UTERUS 


609 


idea  of  the  normal  position  of  the  uterus  wrongly  presupposes  a  distended 
bladder  antl  rectum  occupying  the  anterior  and  the  posterior  thirds 
of  the  pelvic  cavity.  Such  an  arrangement  would  leave  for  the  uterus 
only  the  intermediate  space,  and  would  constitute  a  condition  seldom 
or  never  realized  in  health. 

Suppose  a  straight  line  coincident  with  the  vesicovaginal  wall, 
Figure  345,  to  be  continued  through  the  cervix  to  the  sacrum.  This 
line   represents   approximately   the   anteroposterior   diameter   of   the 


Figure  346 


Correct  drawing  of  the  peMc  organs.     Semi-diagrammatic. 


peh-is.  The  length  of  the  vesicovaginal  wall  is  two  and  a  half  inches, 
and,  supposing  the  cer\'ix  to  be  just  midway  between  the  s^Tnphysis 
and  the  sacrum,  the  distance  from  its  posterior  wall  to  the  sacrum 
must  also  be  two  and  a  half  inches.  Add  to  the  sum  of  these  two 
parts  of  this  anteroposterior  diameter  one  inch  for  the  diameter  of 
the  cer\Tx,  and  the  anteroposterior  diameter  of  the  peh-is  becomes  six 
inches,  instead  of  the  normal  four  and  one-third,  which  proves  that 
the  cer^-ix  must  normally  be  much  nearer  to  the  hollow  of  the  sacrum 
than  to  the  symphysis.     Since  the  length  of  the  vesicovaginal  wall 


610  DISPLACEMENTS 

plus  the  diameter  of  the  cervix  measures  three  and  one-half  inches, 
it  follows  that  the  distance'  from  the  posterior  wall  of  the  cervix  to 
the  hollow  of  the  sacrum  must  be  the  difference  between  four  and  one- 
third  and  three  and  one-half  inches,  or  five-sixths  of  an  inch.  These 
measurements  are  approximations. 

Again,  suppose  the  uterus,  Figure  345,  to  be  carried  bodily  upward 
and  backward,  its  axis  remaining  the  same,  until  the  cervix  reaches  its 
normal  position  near  the  hollow  of  the  sacrum;  then  the  body  of  the 
uterus  would  impinge  upon  the  bony  sacrum.  It  is  therefore  clear 
that  anteversion  must  be  the  normal  position,  because  the  uterus  and 
sacrum  would  otherwise  occupy  the  same  space. 

Figure  346  represents,  according  to  Schultze,^  the  location  and 
position  of  the  virgin  uterus  and  its  surroundings — the  bladder,  rec- 
tum, and  vagina  being  empty  and  collapsed.  The  angle  of  about  90 
degrees  which  the  cervix  forms  with  the  vagina  measures  the  forward 
inclination  of  the  cervix,  but  is  subject  to  variations  in  consequence 
of  the  physiological  movements  of  the  uterus.  The  body  further- 
more is  bent  forward  upon  the  cervix,  so  that  its  anterior  surface  rests 
upon  the  empty  bladder.  The  angle  of  normal  anteflexion,  according 
to  careful  measurements  by  Schultze,  is  about  48  degrees;  Fritsch 
says  that  90  degrees  is  the  physiological  limit.  This  question  will  be 
considered  further  under  the  subject  of  pathological  anteflexions. 


Normal  Movements  of  the  Uterus 

Strictly,  the  uterus  can  have  no  absolutely  normal  position  or  loca- 
tion, because  it  has  a  certain  normal  range  of  movements  that  depend 
to  some  extent  upon  respiration,  intra-abdominal  forces,  and  locomo- 
tion, but  more  especially  upon  the  varying  contents  of  the  rectum  and 
bladder.  The  normal  position  varies  within  the  limits  of  the  normal 
movements.  If  the  body  of  the  uterus  rests  upon  the  bladder,  it  must 
rise  as  the  bladder  becomes  distended;  and,  conversely,  if  the  urine  be 
drawn  through  a  catheter  while  the  woman  is  lying  on  her  back,  the 
uterus,  notwithstanding  the  opposing  influence  of  its  own  weight, 
immediately  follows  the  receding  wall  of  the  bladder  and  returns 
through  an  arc  of  45  degrees,  or  possibly  even  90  degrees,  to  its 
accustomed  position. 

The  full  rectum  forces  the  uterus  in  the  opposite  direction,  toward 
the  symphysis,  and  thereby  counteracts  the  influence  of  the  full  bladder. 
This  anterior  movement  is,  however,  somewhat  limited,  and  is  confined 
to  the  cervical  portion,  except  when  the  body  has  been  fojced  back 
into  close  proximity  with  the  rectum  by  the  overdistended  bladder. 

1  Archiv  fiir  Gynakologie,  1875,  Band  viii,  p.  134,  and  Lageveranderungen  der  Gebarmutter,  Berlin 
1881.  Ely  Van  de  Warker  makes  a  full  and  critical  study  of  the  normal  movements  of  the  unimpreg- 
nated  uterus,  in  the  New  York  Medical  Journal,  xxi,  337;  and  of  the  normal  position  and  movements 
of  the  unimpregnated  uterus,  in  the  American  Journal  of  Obstetrics,  xi,  314.  His  conclusions 
substantially  agree  with  the  later  observations  of  Schultze. 


DISPLACEMENTS  OF  THE   UTEliCS  611 


Normal  Supports  of  the  Uterus 

The  uterus  is  maintained  in  its  normal  position  and  location  by  the 
pelvic  floor,  of  which  the  uterine  lif^anients  are  an  essential  part. 

The  uterine  liganieiits  are  physiolojiically  in  a  state  of  relaxation; 
the  state  of  tension  would  be  pathological;  they  do  not  fix  the  uterus; 
they  tend  only  to  limit  its  movements  to  their  normal  range.  Back- 
ward displacement  of  the  body  is  resisted  by  the  round  ligaments; 
backward  displacement  of  the  cervix,  by  the  uterovesical  ligaments 
and  by  the  vesicovaginal  wall.  Forward  and  downward  displace- 
ments are  resisted  by  the  uterosacral  ligaments,  and  excessive  lateral 
motion  by  the  broad  ligaments.  This  restraining  power  is  doubtless 
greater  in  the  uterosacral  than  in  any  of  the  other  ligaments. 

The  Peine  Floor,  which  is  the  chief  support  of  the  uterus,  is  divided 
into  two  segments,  the  pubic  and  sacral.  The  pubic  segment  includes 
bladder,  urethra,  anterior  vaginal  wall,  and  bladder  peritoneum;  it 
is  attached  in  front  to  the  symphysis  pubis,  and  laterally  to  the 
anterior  bony  walls  of  the  pelvis.  The  sacral  segment  includes  rectum, 
perineum,  posterior  vaginal  wall,  and  strong  tendinous  and  muscular 
tissue;  it  is  attached  to  the  coccyx,  to  the  sacrum,  and  to  the  posterior 
wall  of  the  bony  pelvis. 

Permeating  the  pelvic  floor  in  all  directions,  entering  into  the  com- 
position of  its  single  parts,  binding  them  together,  and  sending  its 
processes  to  the  bony  pelvis,  is  the  pelvic  connective  tissue,  upon  the 
integrity  of  which  largely  depends  the  integrity  of  the  pelvic  floor  as  a 
uterine  support.  The  idea  that  the  uterus  is  supported  by  the  vaginal 
walls,  or  by  the  perineum,  or  by  the  uterine  ligaments  is  obsolete; 
they  are  important  parts  of  the  pelvic  floor,  and  as  such  contribute 
support,  but  the  pelvic  floor  as  a  whole  supports  the  uterus.  The 
various  uterine  supports  are  to  a  great  extent  the  seat  of  motor 
influence.  They  consequently  not  only  resist  excessive  movement, 
but  also  serve  to  return  the  organ  from  its  physiological  migrations. 


Definition  and  Nomenclature  of  Displacements  of  the  Uterus 

In  the  foregoing  pages  the  normal  location,  position,  movements, 
and  supports  of  the  uterus  have  been  outlined.  Those  conditions  are 
pathological  which  induce  changes  to  positions  or  locations  beyond 
the  defined  limits,  or  w^hich  so  fix  the  organ  that  its  normal  move- 
ments are  prevented.  The  displacements  are  divided  into  mal- 
locations  and  malpositions. 

The  Mal-locations,  in  which  the  uterus  occupies  a  place  outside 
its  normal  limits,  are  as  follows: 

Ascent.  •  Antelocation. 

Retrolocation.  Lateral  location. 

Descent. 


612  DISPLACEMENTS 

The  Malpositions  are  determined  by  excessive  change  in  the  inchna- 
tion  of  the  uterine  axis.  They  are  divided  further  into  flexions,  in 
which  the  organ  is  bent  upon  itself  in  an  abnormal  degree,  manner, 
or  direction;  and  versions,  in  which  the  axis  of  the  unflexed  uterus 
inclines  in  an  abnormal  degree  or  direction.  The  malpositions  there- 
fore are: 

Retroversion.  Lateral  flexion. 

Retroflexion.  Anteversion. 

Lateral  version.  Anteflexion. 

Symptoms  and  Diagnosis  of  Displacements  in  General 
of  the  Uterus 

Each  variety  of  displacement  may  be  indicated  by  its  own  group 
of  symptoms  and  physical  signs.  These  will  be  presented  in  the  study 
of  special  displacements.  To  avoid  repetition,  those  symptoms  and 
signs  which  pertain  to  no  special  displacement,  but  which  belong 
to  all  alike,  will  be  mentioned  at  once.  They  may  arise  either  from 
the  displacement  itself  or  from  possible  complications,  of  which  the 
following  are  examples:  metritis,  ovaritis,  salpingitis,  atresia,  stenosis, 
cystitis,  vesical  catarrh,  rectitis,  rectal  catarrh,  perimetritis,  peritonitis, 
uterine  catarrh,  tumors,  and  cicatrices. 

Uterine  displacement  may  be  a  cause  or  an  efi^ect  of  associated  com- 
plications; or,  together  with  them,  it  may  be  a  concurrent  result  of  some 
common  cause;  or  it  may  have  had  primarily  no  pathological  connec- 
tion with  them.  The  symptoms  of  displacement  refer  to  the  pelvic 
organs  or  to  the  nervous  system. 

Among  the  symptoms  or  associated  lesions  which  refer  to  the  pelvic 
organs  are: 

Difficult  walking  and  standing.       Pelvic  pain. 

Dysmenorrhoea.  Menorrhagia. 

Sterility.  Frequent  abortion. 

Constipation.  Painful  or  difficult  defecation. 

Dysuria.  Polyuria. 

Tenesmus. 
Among  the  symptoms  or  associated  lesions  which  refer  to  the  nervous 
system  are: 

Neuralgia  in  various  parts.  Motor  disturbances. 

Hysteria.  Nervous  dyspepsia. 

Anaemia.  Chlorosis. 

Spinal  irritation. 
The  final  diagnosis  must  depend  always  upon  direct  examination 
of  the  uterus  itself.  The  first  division  of  the  above  group  of  symptoms 
is  not  likely  to  escape  notice  as  indicative  of  displacement,  but  the 
nervous  symptoms  are  disregarded  constantly  or  treated  without 
reference  to  their  possible  pelvic  origin.  The  frequent  dependence 
of  these  nervous  phenomena  upon  displacement  is  proved  by  their 
persistence  in  many  cases  after  ordinary  treatment,  by  their  prompt 


DISPLACEMENTS  OF   THE  I'TERUS  013 

disapi)(.'arance  upon  permanent  replacement  and  retention  of  the 
uterus  by  mechanical  means,  and  by  their  usually  prompt  recurrence 
upon  removal  of  the  support.  The  presence,  therefore,  of  the  second 
division  of  the  group,  or  any  part  thereof,  even  thouii;li  the  first  be 
absent,  will  justify  a  careful  investigation  into  the  state  of  the  pelvic 
organs. 

Examination  that  results  only  in  giving  the  name  to  a  special  variety 
of  displacement,  and  does  not  include  the  complicating  lesions,  would 
not  furnish  a  sufficient  guide  to  the  therapeutic  indications,  and  is 
therefore  inadequate.  Successful  treatment,  for  instance,  of  an  ante- 
flexion dependent  upon  inflammation  of  the  uterosacral  ligaments 
must  include  removal  of  the  inflammation. 

An  important  prerequisite  to  examination  is  the  absence  of  con- 
tents in  the  rectum  and  bladder.  The  full  rectum  distorts  the  vaginal 
walls,  deprives  the  examiner  of  the  space  necessary  for  introduction 
of  the  speculum,  and  throws  the  uterus  out  of  its  accustomed  position. 
jNIuch  more  troublesome  is  the  presence  of  even  a  small  quantity  of 
urine  in  the  bladder,  because  it  makes  the  abdominal  muscles  tense 
when  the  hand  is  placed  over  the  lower  portion  of  the  abdomen  for 
bimanual  palpation,  and  makes  it  difficult  to  engage  the  uterus  between 
the  hand  and  the  examining  finger.  The  distended  bladder,  by  pushing 
the  uterus  upward  and  backward,  makes  bimanual  palpation  almost 
useless.  It  is  not  surprising  that  conflicting  opinions  are  common, 
when  one  day  the  patient  is  examined  with  rectum  and  bladder  full, 
another  day  T^dth  these  organs  empty;  one  day  in  the  dorsal,  another 
day  in  Sims'  or  the  knee-breast  position;  one  day  with  the  cylindrical 
or  bivalve  speculum,  another  day  with  Sims'  or  Simon's.  The  left- 
hand  method  of  examination  is  incomparably  superior  to  the  right. 
The  palmar  surface  of  the  left  index-finger  has  a  more  acute  and  more 
easily  educated  tactile  sense,  and  is  directed  more  easily  toward  the 
left  side  of  the  pelvis,  which  is  especially  subject  to  disease.  The 
stronger  right  hand  should  be  free  to  palpate  the  surface  of  the  abdomen 
in  conjoined  manipulation. 

For  digital  examination  the  dorsal  position  is  preferred:  the  patient 
should  be  drawn  close  to  the  edge  of  a  bed,  or  preferably  a  table,  the 
thighs  being  flexed,  the  feet  about  fifteen  inches  apart,  and  knees  widely 
separated.  The  examiner  should  stand  facing  the  patient  or  at  her  left 
side.  The  index-finger  of  the  left  hand,  properly  lubricated,  then  slowly 
advances  over  the  perineum  into  the  vagina,  noting  the  condition  of  the 
perineum,  the  presence  or  absence  of  cicatrices,  lacerations,  tumors, 
or  relaxation  of  the  vagina  or  perineum,  the  capacity  of  the  vagina, 
the  condition,  size,  and  direction  of  the  cervix,  its  distance  from  the 
sacrum  and  vulva,  its  mobility  or  fixation.  Now,  the  right  hand  is 
pressed  well  down  behind  the  pubes,  and  the  uterus  is  engaged  between 
it  and  the  examining  finger.  See  Chapter  III.  In  this  way  the  examiner 
may  determine  quite  accurately  the  position,  location,  and  size  of  the 
entire  organ;  may  detect  the  possible  presence  of  complicating  tumors, 
both  inflammatory  and  non-inflammatory;  may  also  note,  if  possible, 


614  DISPLACEMENTS 

the  location  and  condition  of  the  ovaries,  which,  especially  in  posterior 
displacements,  are  liable  to  be  prolapsed  and  excessively  sensitive, 
and  to  constitute,  therefore,  a  most  intractable  complication.  The 
index-finger  sweeps  around  the  cervix  in  search  of  tender  places  which 
may  be  the  result  of  inflammation  or  the  expression  of  some  neurosis. 
Above  all,  the  digital  examination  requires  a  light,  gentle,  delicate 
touch.  The  index-finger  may  now  be  removed  and  reintroduced  into 
the  rectum,  the  right  hand  still  being  behind  the  pubes,  or  the  cervix 
may  be  grasped  between  the  index-finger  in  the  rectum  and  the  thumb 
in  the  vagina,  picked  up,  as  it  were,  between  the  finger  and  the  thumb 
thus  placed,  and  with  the  aid  of  the  right  hand  behind  the  pubes 
thoroughly  palpated. 

Adequate  diagnosis  of  the  position  of  the  pelvic  organs  usually  is 
made  by  touch  and  conjoined  palpation.  It  is  seldom  necessary  or 
desirable  to  sound  or  probe  the  uterine  cavity  in  order  to  learn  the 
position  of  the  uterus;  indeed,  accurate  information  in  the  majority 
of  cases  can  be  gained  more  readily  and  more  safely  by  touch  alone. 
A  tumor  or  inflammatory  mass  in  the  pelvis  may  be  confused  with 
the  uterus.  In  such  a  case  the  uterus  may  be  located  definitely — 
relative  position  determined — by  the  sound  or  probe.  ^Mien  the  uterine 
canal  thus  is  explored,  the  patient  may  be  on  her  back,  and  the  left 
index-finger  in  the  vagina  may  be  used  as  a  guide.  The  exploration, 
however,  is  made  most  effectually  and  gently  with  Sims'  speculum, 
the  patient  being  in  the  left  lateroprone  position.  In  some  cases  the 
probe  cannot  be  passed  by  any  other  method.  The  bivalve  and  cylin- 
drical specula  are  unsatisfactory  in  explorations  of  the  interior  of  the 
uterus. 


CHAPTER   XXXIX 
MAI^LOCATIONS  OF  THE  UTERUS 


Ascent.    Retrolocation.    Antelocation.    Lateral  Locations. 
Descent  or  Prolapse 

ASCENT  OF  THE  UTERUS 

Ascent  of  the  uterus  may  result  from  traction  above  or  pressure 
below.  The  organ  may  be  drawn  upward  and  backward  by  a  contrac- 
tion of  the  uterosacral  ligaments,  which  results  from  inflammation, 
and  which  usually  induces  a  troublesome  form  of  anteflexion.  The 
enlarged  pregnant  uterus  sometimes  becomes  attached  by  adhesive 

Figure  347 


Schematic  drawing  of  various  mal-locations. 

inflammation  to  a  portion  of  the  peritoneum  in  one  of  the  higher  zones 
of  the  pelvis  or  in  the  abdomen,  and  the  organ  may  remain  consequently 
fixed  in  its  elevated  position  after  involution.  A  tumor  connected  with 
the  uterus  or  its  appendages  which  has  grown  too  large  to  be  retained 
in  the  pelvis  may,  upon  rising  into  the  abdomen,  drag  the  uterus  with  it. 
Pressure  below  may  come  from  excessive  distension  of  the  rectum  or 

(615) 


616  DISPLACEMENTS 

bladder,  or  from  a  large  accumulation  of  menstrual  fluid  in  the  vagina, 
or  from  a  tumor  originating  in  any  portion  of  the  pelvis  below  the  level 
of  the  uterus. 

RETROLOCATION    OF    THE    UTERUS 

The  uterus  may  be  forced  back  into  a  post-normal  location  by  the 
presence  of  a  tumor  in  front  of  it  or  by  the  distended  bladder,  or  it 
may  be  drawn  back  and  fixed  by  peritoneal  adhesions.  Retrolocation 
is  liable  to  induce  vesical  irritation  by  putting  the  vesicovaginal  wall 
on  the  stretch,  and  thereby  dragging  on  the  neck  of  the  bladder. 

ANTELOCATION    OF   THE   UTERUS 

The  causes  of  this  displacement  are  similar  to  those  which  produce 
retrolocation;  they  are:  distention  of  the  rectum,  post-uterine  hsema- 
tocele,  post-uterine  tumors  and  swellings,  contraction  of  the  bladder, 
and  peritoneal  adhesions.  Antelocation  often  causes  vesical  irritation, 
consequent  upon  the  invasion  by  the  uterus  of  space  which  belongs  to 
the  bladder. 

LATERAL  LOCATION  OF  THE  UTERUS 

The  entire  uterus  often  is  displaced  to  the  right  or  to  the  left  by 
a  tumor  or  by  an  inflammatory  mass.  In  either  case  the  uterus  is 
crowded  to  the  opposite  side  of  the  pelvis.  After  resolution  of  an 
inflammatory  mass  the  broad  ligament  and  adjacent  inflamed  struc- 
tures, shortened  by  cicatricial  contraction,  draw  the  uterus  to  the 
affected  side  and  fix  it  there.  Laceration  of  the  cervix  opens  the  way 
to  infection,  and  therefore  often  is  followed  by  inflammation  in  the 
parametrium  on  the  corresponding  side. 

Diagnosis,  Symptoms,  and  Treatment  of  Ascent,  Retrolocation, 
Antelocation,  and  Lateral  Location  of  the  Uterus 

The  diagnosis,  symptoms,  and  treatment  of  the  above  mal-locations 
are  wholly  subordinate  to  the  more  significant  lesions  of  which  they 
are  only  the  incidental  results. 

The  Treatment  for  mal-locations  due  to  inflammatory  causes  is  the 
same  as  that  for  the  inflammation.  The  indications  for  topical  treat- 
ment and  surgical  measures,  including  operations  on  the  uterus  and 
its  appendages  and  the  removal  of  tumors,  will  vary  with  the  causa- 
tive lesions.  In  many  cases  mal-locations  of  the  uterus  give  rise  to 
no  symptoms,  and  therefore  require  no  treatment.  Pessaries  for  all 
mal-locations  {not  malpositions)  except  descent  are  useless,  and  may  be 
harmful. 

DESCENT    OR   PROLAPSE    OF    THE   UTERUS 

The  nature  of  this  displacement  is  indicated  clearly  by  the  name. 
It  is  convenient  to  distinguish  three  degrees  of  descent: 


MA].-IJ>(',\TI()\S   OF    Till':   I'TERUS  (".17 

First  Degree:  'I'lic  uterus  is  displaced  downward  until  sufficient 
si)ace  lias  heen  rained  l)et\veeu  tlie  cervix  and  tlie  sacrum  to  ])crmit 
tile  cori)us  to  turn  hack  into  extreme  retroversion. 

Second  Degree:  The  cervix  descends  to  the  \  ul\  a. 

Third  Degree:  Tlie  uterus  i)rotrudes  ])artially  or  wholly  throii^di  the 
vulva.     The  third  (le<;re(>  of  descent  sometimes  is  called  i)roci(lentia. 

Etiology  and  Mechanism  of  Descent  of  the  Uterus 

Descent  may  be  the  result  of  any  or  all  of  tlie  following  causes:' 

1.  Pressure  from  above. 

2.  Weakening  of  the  uterine  supports. 

3.  Increased  weight  of  the  uterus. 

4.  Traction  from  below. 

Any  of  the  above  conditions  being  the  primary  cause,  the  others 
singly  or  combined  may  result. 

1.  Pressure  from  Above. — Under  this  head  may  be  included: 

a.  Pelvic  or  abdominal  tumors. 

b.  Ascites. 

c.  Tight  or  heavy  clothing. 

d.  Straining  at  stool. 

e.  Muscular  exertion. 
/.  Fecal  accumulations. 

g.  Habitual  overdistension  of  the  bladder. 

2.  Weakening  and  Relaxation  of  the  Uterine  Supports  may  be 
consequent  upon: 

a.  Subinvolution. 

b.  Senile  atrophy  of  the  pelvic  floor. 

c.  Abnormally  large  pelvis. 

d.  Increased  weight  of  the  uterus. 

e.  Puerperal  traumatisms. 
/.  Pressure  from  above. 

g.  Traction  from  below. 

3.  Increased  Weight  of  the  Uterus.— Among  the  pathological 
developments  w-hich  cause  increased  weight  are: 

a.  Congestion. 

b.  Subinvolution. 

c.  Metritis. 

d.  Pregnancy. 

e.  Fluid  in  the  endometrium. 
/.  l^terine  tumors. 

4.  Traction  from  Below  may  be  due  to  such  causes  as: 

a.  Vaginal  cicatrices. 

b.  Falling  of  the  pelvic  floor. 

c.  Contraction  and  congenital  shortening  of  the  vagina. 

d.  Tumors  of  the  cervix  or  vagina. 


1  Adaoted  from  Thomas'  Diseases  of  Women. 


38 


618 


DISPLACEMENTS 

Figure  348 


Uterus  between  first  and  second  degrees  of  descent.     Rectocele  and  cystocele.     Semi-diagrammatic. 

Figure  349 


Second  degree  of  descent.    Cervix  appears  at  the  vulva.    Rectocele  and  cystocele.    Semi-diagrammatic. 


MAL-LOCATIONS  OF  THE  UTERUS 


619 


Complete  or  third  degree  of  descent.     Rectocele  and  cystocele.     Rectocele  forms  a  pouch  in  which 
scybalse  may  accumulate.     Semi-diagrammatic. 


Figure  351 


Complete  or  third  degree  of  descent.  Vaginal  wall  peeled  off  from  the  rectum  leaving  the  rectal 
wall  in  normal  position.  Cystocele  extreme;  no  rectocele.  Semi-diagrammatic.  Bladder  displaced 
with  the  uterus. 


620  DISPLACEMENTS 

Uterogestation,  parturition,  and  the  puerperium  may  be  followed 
by  increased  weight  of  the  uterus  and  weakening  of  the  supports  from 
subinvolution.  Puerperal  traumatism  may  injure  the  vaginal  outlet 
and  cause  the  vaginal  walls  to  fall;  these  in  turn  may  drag  the  uterus 
down  after  them;  indeed,  excessive  descent  of  the  vaginal  walls  usually 
is  due  to  parturition.  Obviously,  descent  of  the  vesicovaginal  and 
rectovaginal  walls,  or,  more  comprehensively,  the  sacral  and  pubic 
segments  of  the  pelvic  floor,  involves  also  concurrent  descent  of  the 
uterus  and  its  appendages.  It  is  clear  from  the  above  that  descent 
of  the  vagina  must  be  studied  in  connection  with  the  descent  of  the 
uterus. 

In  labor  the  anterior  wall  of  the  vagina  is  so  depressed,  stretched, 
and  shortened  by  the  advancing  head  of  the  child  that  during  and  after 
the  second  stage  the  anterior  lip  of  the  cervix  may  be  seen  behind  the 
urethra.  If  the  puerperium  progresses  favorably,  with  prompt  involu- 
tion of  the  uterus,  vagina,  perineum,  and  peritoneum,  the  relaxation 
of  the  vesicovaginal  wall  and  of  the  uterosacral  supports  disappears 
and  the  uterus  resumes  its  normal  multiparous  location  and  position. 
But  if  the  enlarged  uterus  remains  in  the  long  axis  of  the  vagina,  wdth 
its  fundus  incarcerated  in  the  hollow  of  the  sacrum  between  the  utero- 
sacral ligaments,  and  with  its  sacral  supports  stretched  for  so  long  a 
time  that  they  cannot  recover  their  contractile  power,  and  with  involu- 
tion of  all  the  pelvic  organs  arrested,  the  descent  may  not  only  persist, 
but  may  even  progress,  with  constantly  increasing  protrusion  of  the 
vesicovaginal  wall — cystocele — to  the  third  degree  of  prolapse.  The 
downward  influence  of  the  above  conditions  may  be  increased  mate- 
rially by  rupture  of  the  perineum  and  consequent  prolapse  of  the  recto- 
vaginal wall  into  a  pouch,  called  redocele. 

In  the  great  majority  of  cases  of  complete  prolapse  the  posterior 
vaginal  wall  in  its  descent  is  peeled  off  from  the  rectum,  as  shown  in 
Figure  351,  leaving  the  latter  in  the  normal  position.  In  rare  instances 
the  lower  portion  of  the  rectum  also  is  found  to  have  extruded  in 
extreme  rectocele,  making  a  pouch  below  and  in  front  of  the  anus,  in 
which  fecal  matter  may  accumulate  and  remain  as  hard  scybalse. 
See  Figure  350. 

Obviously,  complete  prolapse  of  the  uterus  is  only  an  incident  to 
prolapse  of  the  pelvic  floor.  The  whole  mechanism  is  in  all  respects 
analogous  to  that  of  hernia.  The  extruded  hernial  mass  drags  after  it 
a  peritoneal  sac,  which,  hernia-like,  contains  small  intestine.  This  sac 
forces  its  way  to  the  pelvic  outlet  and  extrudes  through  the  vulva, 
having  the  inverted  vagina  for  a  covering. 

In  the  first  degree  of  descent,  Figure  348,  as  we  have  said,  the  uterus 
is  displaced  downward  and  forward  sufficiently  to  permit  the  body  to 
turn  back  into  retroversion;  as  already  stated,  the  organ  in  its  normal 
location  cannot  retrovert,  because  in  so  doing  it  would  impinge  upon 
the  bony  sacrum.  As  a  consequence  of  the  first  degree  of  descent 
there  are  two  significant  possibilities :  First,  as  the  uterus  falls  to  a  lower 
level,  where  it  would  crowd  upon  and  irritate  the  bladder,  its  long 


MAL-LOCATIOMS  OF  THE  VTERVS 


021 


axis  usually  changes  so  as  more  and  more  to  conform  to  that  of  tlie 
vasjjina,  the  cervix  moves  toward  the  j)ul)es,  and  the  corpus  toward 


Fh;ruK  .'>.'i2 


Figure  352. — Descent  of  the  uterus  to  the  third  degree.  The  cervix  appears  at  the  vulva  carr>-ing 
with  it  the  vesicovaginal  and  rectovaginal  walls;  that  is,  the  rectum  and  bladder  are  in  descent  together 
with  the  uterus,  having  dragged  the  uterus  down  with  them. 

Figure  353. — Descent  of  the  uterus  to  the  third  degree.  The  cervix  appears  at  the  vulva,  not 
dragged  down  by  the  prolapsing  rectum  and  vagina,  but  dragging  them  down  after  it,  as  shown  in 
section  in  Figure  356. 


Figure  354 


Figure  355 

■tjk 

/3r"*\ 

jjp^ 

V 

j 

K«ML 

h 

^ 

|Hfe-^g^^ 

B|^Hj.< 

Figure  354. — Complete  descent  of  the  uterus,  vagina,  and  bladder  with  ulceration  of  exposed 
surfaces.  The  os  externum  is  at  the  bottom  of  the  picture.  That  portion  of  the  sound  which  is  in  the 
bladder  is  shown  by  dotted  lines.  .  ,       ^         ,  ^     •     , 

Figure  355. — Complete  descent  of  the  retrofiexed  uterus;  the  cervix  and  external  os  uteri  show 
in  the  upper  part  of  the  prolapsed  structures  and  the  corpus  uteri  in  the  lower  part. 


622 


DISPLACEMENTS 


the  sacrum— that  is,  it  turns  back  away  from  the  bladder  into  retro- 
version; this  is  as  if  the  irritated  bladder,  in  the  protection  of  its  own 
rights  and  territory,  had  thrown  the  uterus  back;  second,  instead  of 
turning  back  into  retroversion,  the  uterus  simply  may  change  its  loca- 
tion to  a  lower  level,  while  the  position  remains  the  same — that  is,  the 
organ,  still  retaining  its  normal  position  of  anteversion  and  anteflexion, 
simply  may  settle  to  a  lower  plane.  It  must  then  occupy  space  that 
belongs  to  the  bladder.  The  normally  ante  verted  and  anteflexed  uterus 
in  such  descent  is  much  more  palpable  to  digital  examination,  and  for 


Figure  356 


Figure  357 


Figure  356. — Descent  of  the  virgin  uterus  into  the  vaginal  canal,  showing  reduplicated  vaginal 
walls.  The  uterovaginal  attachment,  points  X  and  Z,  appears  to  be  at  X'  and  Z' .  The  apparent 
increase  of  length  in  the  vaginal  portion  of  the  cervix,  due  to  the  redupUcation,  is  measured  by  th& 
distance  from  A'  and  Z  to  X'  and  Z' . 

Figure  357. — Descent  of  the  uterus,  showing  excessive  circular  enlargement  of  the  lacerated  cervix, 
consequent  upon  redupUcation  of  the  vaginal  walls  and  outrolUng  of  intracervical  tissues.  The  divided 
fragments  of  the  os  externum  are  at  a  and  h.  The  curved  lines  forming  the  angles  1,  2,  3,  and  4  indicate 
the  gradual  process  of  eversion.  The  angle  of  the  laceration  originally  at  point  1  has  been  forced  down 
by  the  swelling  and  outroUing  of  the  mucous  and  submucous  tissues  of  the  cervix  to  point^4.  The 
apparent  os  externum  is  at  point  4.  The  uterovaginal  attachment  A'  and  Z  seems  to  be  at  X  and  Z  . 
The  vaginal  portion  of  the  cervix  therefore  appears  much  larger  and  longer  than  it  actually  is.  Thia 
is  rather  descent  by  outroUing  of  the  cervical  mucosa  rather  than  of  the  entire  uterus. 


this  reason  the  vesical  irritation  consequent  upon  the  descent  often 
has  been  attributed  wrongly  to  the  anteversion  and  anteflexion.  In 
this  way  much  confusion  has  arisen  in  the  effort  to  draw  the  line 
between  normal  and  pathological  anterior  positions.  The  prompt 
relief  which  follows  permanent  replacement  of  the  organ  to  the  normal 
location,  even  though  in  so  doing  the  anteposition  be  exaggerated, 
proves  that  the  symptoms  depend  upon  the  mal-location,  not  upon  the 
anteposition.  The  importance  of  a  clear  distinction  therefore  between 
location  and  position  becomes  apparent. 

Another  cause  of  vesical  irritation  is  the  dragging  of  the  uterus. 


MAL-LOCATIOXS  OF   THE   ITERUS  623 

upon  tlie  nec-k  of  the  hladdtT.    This  traction  occurs  not  only  in  ascent, 
hut  also  when  the  organ  descends  lielow  a  certain  le\el. 

In  the  foregoing  paragraphs  traction  due  to  the  falling  pelvic  floor 
has  hecn  discussed  as  a  cause  of  descent.  Impairment  of  the  uterine 
su{)i)orts  may,  however,  he  such  that,  instead  of  falling  and  dragging 
the  uterus  after  them,  they  simply  permit  it  to  descend  along  the 
vaginal  canal  by  the  force  of  its  own  weight,  and  to  carry  with  it  the 
reduplicated  vaginal  walls.  This  influence  is  enforced  generally  by 
increased  weight  of  the  diseased  organ.  The  vagina  more  readily  be- 
comes a  track  for  the  descending  uterus  when  from  any  cause  the  normal 
forward  direction  of  the  \'aginal  canal  changes  toward  the  vertical; 
this  change  in  the  direction  of  the  \agina  may  occur  either  as  the  result 
of  forward  displacement  of  its  upper  extremity  or  of  retrodisplacement 
of  its  lower  extremity.  The  former  involves  anteposition  of  the  cervix; 
the  latter,  backward  displacement  of  the  perineum.  For  a  full  discus- 
sion of  backward  displacement  of  the  lower  part  of  the  vagina  and  vulva 
toward  the  coccyx,  see  Laceration  of  the  Perineum  and  Injuries  of  the 
Pelvic  Floor,  in  Chapter  XXXVL  When  the  uterus  descends  along 
the  track  of  the  vagina,  the  long  axes  of  the  two  organs  will  correspond; 
hence,  such  descent  must  involve  a  degree  of  retroversion.  See 
Figure  359. 

Pathology  of  Descent  of  the  Uteras 

The  pathology  may  involve  all  the  displaced  organs.  The  circu- 
lation throughout  the  pelvis  is  impeded  by  traction  upon  the  vessels; 
the  entire  pelvic  contents  therefore  become  the  subject  of  venous 
congestion,  with  consequences  disastrous  to  local  innervation  and 
nutrition.  The  ovaries  and  Fallopian  tubes  suffer  concurrent  displace- 
ment. That  portion  of  the  peritoneum  which  enters  into  the  formation 
of  the  uterine  ligaments  and  of  the  pelvic  floor  is  dragged  along  with 
the  uterus.  The  vagina,  also  displaced,  may  become  h^-pertrophied, 
swollen,  and  inflamed. 

Sometimes  the  cul-de-sac  of  Douglas  is  distended  by  downward 
pressure  of  the  intestine,  by  a  small  tumor,  or  by  ascitic  fluid,  and 
a  consequent  hernial  sac  may  protrude  into  the  vagina  through  some 
portion  of  the  posterior  vaginal  fornix.  The  anterior  fornix  is  subject 
to  a  similar  accident.  These  conditions  are  designated  enterocele 
raginalis  anterior  and  posterior. 

In  the  third  degree  of  descent  the  vagina,  now  rolled  out  and 
exposed  to  external  conditions,  is  no  longer  lubricated  and  protected 
by  normal  secretions,  and  therefore  it  becomes  dry,  parchment-like, 
oedematous,  eroded,  and  perhaps  ulcerated. 

The  rectum  and  bladder  are  subject  to  infection  and  chronic  catarrh, 
and  to  concurrent  descent.  The  uterus  may  be  enlarged  from  any  one 
or  all  of  a  variety  of  causes:  congestion,  subinvolution,  h\-pertrophy, 
and  h\'perplasia.  The  cervix  is  often  the  seat  of  extreme  erosion  or 
ulceration.  The  endometrium,  in  order  to  relieve  the  organ  of  sm^plus 
blood,   gives   forth   an   excessive   secretion  of   vitiated   mucus.      The 


624 


DISPLACEMENTS 


enlargement  of  the  uterus,  if  the  cervix  is  lacerated,  often  pertains 
more  to  the  cervix  than  to  the  body,  especially  in  prolapse  of  the 
second  and  third  degrees.  An  explanation  of  this  may  be  found  in 
Figures  356  and  357. 

Apparent  elongation  and  disproportionate  circular  enlargement  of 
the  cervix  are  conditions  which  many  standard  authors  wrongly  call 
hypertrophic  elongation  and  circular  hypertrophy.  The  question  of 
infravaginal  elongation  is  easily  settled  by  placing  the  patient  in  the 
knee-breast  position.  Then  the  uterus,  by  its  own  weight,  falls  toward 
the  diaphragm,  the  reduplicated   vagina  unfolds,  and  the  apparent 


Figure  358 


This  cut  is  from  a  part  of  an  illustration  in  a  standard  text-book.  It  is  reproduced  to  illustrate  the 
current  misconception  of  complete  prolapse  and  apparent  elongation  of  the  cervix.  The  apparent 
elongation  almost  invariably  disappears  on  replacement  of  the  uterus.  The  appearance  of  elongation 
is  due  to  congestion  and  vaginal  reduplication.  Amputation  of  such  a  cervix,  so  often  ad-\-ised,  would 
be  apt  to  involve  the  bladder  in  front  and  the  cul-de-sac  of  Douglas  behind.  Actual  elongation  of 
the  cervix  has  seldom  been  demonstrated  satisfactorily.  Elongation,  if  present  at  all,  is  almost  always 
at  least  in  the  supravaginal,  not  the  infravaginal  portion  of  the  cervix.  The  uterovaginal  attachment 
cannot  be  therefore  as  indicated  at  Z  Z;  it  is  on  a  plane  sHghtly  above  X  X. 


uterovaginal  attachment.  A"'  Z',  Figures  356  and  357,  disappears, 
disclosing  the  actual  attachment,  A'  Z.  Further,  the  point  of  the  sound, 
passed  into  the  bladder  while  the  cervix  is  exposed  by  Sims'  speculum, 
may  be  placed  against  the  anterior  wall  of  the  cervix  at  Z,  which  would 
be  impossible  if  the  attachment  were  at  Z'. 

The  comparatively  small  amount  of  h\'pertrophy  in  disproportionate 
circular  enlargement  due  to  an  associated  laceration  of  the  cervix 
uteri  is  proved  by  the  operation  of  trachelorrhaphy  or  by  rolling  in 
the  outrolled  tissues  with  uterine  tenacula,  as  shown  in  Figure  306. 
When  the  outrolled  intra  cervical  mucous  tissues  are  rolled  in,   the 


MAL-LOCATIONS  OF  THE   UTERUS  G25 

proper  diameter  of  the  eervix  is  restored,  and  a  laceration  on  one  or 
both  sides,  extending  past  tiie  vaginal  attachment,  becomes  apparent. 
Those  cases  in  which  reduphcation  of  the  vaginal  walls  does  not 
almost  entirely  explain  the  great  elongation  so-called,  or  in  which  great 
disproportionate  circular  enlargement  has  not  been  caused  by  an 
associated  laceration  of  the  cervix,  are  the  rare  exceptions.  Formerly 
these  mechanical  conditions  were  attributed  to  hypertrophic  changes, 
and  were  regarded  as  adequate  indications  for  removal  of  the  cervix. 
Such  elongation  as  is  shown  in  Figure  35S  rarely,  if  ever,  exists.  Emmet, 
with  his  enormous  experience,  has  never  seen  such  a  case,  and  denies 
its  existence.  Congestion  of  the  prolapsed  uterus  consequent  upon 
obstruction  in  the  stretched  and  displaced  veins  is  often  so  extreme  as 
to  induce  a  state  analogous  to  erection.  Measurements  by  the  probe 
just  before  and  a  few  minutes  after  replacement  generally  show  a  very 
appreciable  decrease  in  the  length  of  the  uterine  canal.  If  the  prolapse 
has  been  of  the  third  degree,  the  difference  may  amount  to  one  or  even 
two  inches.  It  is  clearly  important  not  to  confound  the  enlargement 
of  congestion  with  increase  in  the  solid  constituents  of  the  organ. 
See  Laceration  of  the  Cervix.  The  great  merit  of  having  secured  gen- 
eral assent  to  the  foregoing  propositions,  and  of  having  given  to  the 
subject  a  new  and  right  direction,  must  be  accorded  to  Emmet.  The 
cervix  now  seldom  is  amputated  for  so-called  hypertrophy. 

Symptoms  and  Course  of  Descent  of  the  Uterus 

The  course  of  descent  is  ordinarily  chronic,  but  intercurrent  attacks 
of  acute  vaginitis  are  rather  common.  Peritonitis  sometimes  efi'ects  a 
spontaneous  cure  by  peritoneal  adhesions  that  fasten  the  uterus  in  an 
elevated  position  and  hold  it  permanently.  The  symptoms  of  descent 
may  be  so  severe  as  to  incapacitate  the  patient,  or  they  may  be  attended 
with  very  little  discomfort;  the  usual  symptoms  are  these: 

1.  Abdominal  pains. 

2.  Dragging  pains  in  the  pelvis  extending  to  the  thighs. 

3.  Functional  disturbances  of  the  bladder  and  rectum — tenesmus. 

4.  In  cases  of  complete  prolapse:  suffering  from  excoriation  or 

ulceration  of  the  exposed  vagina  or  cer\dx  uteri. 

5.  Great  irritation  from  vaginitis  and  pain  from  possible  peritonitis. 

6.  Uterine  hemorrhages  and  other  menstrual  disorders — frequent. 

7.  Leucorrhcea. 

8.  Sterility. 

Diagnosis  and  Differential  Diagnosis  of  Descent  of  the  Uterus 

The  diagnosis  is  by  inspection,  palpation,  and  exploration.  The  pro- 
lapsed uterus  may  be  distinguished  from  cystocele,  rectocele,  inverted 
uterus,  vaginal  cysts,  and  fibroid  tumor  by  the  presence  of  the  os  exter- 
num. The  length  of  the  uterus  may  be  measured  by  the  sound;  the 
size,  shape,  position,  extent  of  descent,  and  difficulty  of  replacement 
may  be  determined  by  conjoined  manipulation. 


626  DISPLACEMENTS 

Diagnosis  of  the  Associated  Cystocele  and  Rectocele 

Cystocele  may  be  recognized  by — 

a.  A  convex  'protrusion  between  the  labia  covered  with  rugous 

vaginal  mucosa,  easily  pushed  back,  and  diminishing  when 

the  patient  lies  down. 
h.  A  sound  in  the  bladder  may  be  felt  by  the  finger  against  the 

protrusion,  thereby  demonstrating  it  to  be  continuous  with 

the  vesicovaginal  wall  and  formed  of  it. 
c.  After  urination  there  w^ill  remain  residual  urine  in  the  pro- 
truding sac.     This  often  causes  cystitis  and  stone  in  the 

bladder. 
Eectocele  may  be  recognized  by — 

a.  Bulging  forward  of  the  posterior  vaginal  wall,  the  protruding 

mass  being  covered  with  rugous  vaginal  mucosa. 
h.  Mass  increasing  in  size  on  straining  at  stool  and  diminishing 

on  lying  down. 

c.  Finger  in  the  rectum,  which  enters  the  protruding  mass,  and 

demonstrates   it   to   be   continuous   with   the   rectovaginal 
septum  and  composed  of  it. 

d.  Lodgement  of  feces  in  the  pouch  and  prevention  of  complete 

emptying  of  the  bowel;  it  may  be  necessary  to  facilitate 
defecation  by  pushing  the  pouch  back  with  the  finger. 
Cystocele  and  rectocele  are  apt  to  be  associated  with  intermittent 

accumulations  of  air  in  the  vagina,  which  may  be  expelled  with  a 

peculiar  sound — so-called  garrulity  of  the  vulva. 

Prophylaxis  of  Descent  of  the  Uterus 

Prophylaxis  requires  such  measures  during  labor  as  will  prevent 
long  and  powerful  pressure  upon  the  pelvic  floor.  After  labor  any 
injury  to  the  perineum  should  be  repaired  promptly.  The  vulva 
should  be  kept  clean  by  external  irrigations  and  kept  covered  by  a 
sterile  pad.  The  urine,  if  retained,  should  be  drawn  regularly  and 
the  bowels  moved  daily  without  straining.  If  conditions  be  present 
likely  to  induce  subinvolution,  such,  for  example,  as  pelvic  infection 
and  laceration  of  the  cervix,  they  should  receive  treatment  at  the 
proper  time.  Undue  relaxation  of  the  pelvic  floor  necessitates  pro- 
longed rest  in  bed,  the  use  of  astringent  douches,  and  when  the 
patient  resumes  the  upright  position,  the  application  of  a  pessary. 
If  involution  goes  on  with  the  uterus  congested  and  irritated  by 
descent,  the  result  is  apt  to  be  perpetuation  of  the  displacement  and 
its  attendant  evils;  it  is  therefore  highly  desirable  that  the  uterus  be 
kept  in  place  during  the  puerperium;  to  this  end,  even  while  the  patient 
is  in  bed,  a  pessary  may  be  indicated.  Under  all  conditions  the  great 
prophylactic  value  of  rest  in  bed,  prolonged  for  seven  or  eight  weeks 
after  labor,  is  undeniable.  The  puerperium  offers  the  best  conditions 
for  the  prophylaxis  and  cure  of  descent. 


MAL-LOCATIONS  OF   THE   UTERUS  627 

Treatment  of  Descent  of  the  Uterus 

Treatment  may  be  surgical  or  iion-surijjical. 

Non-surgical  Treatment 

Replacement. — The  first  indication  is  replacement,  which,  in  the 
first  and  second  degrees  of  descent,  is  not  difficult  unless  the  uterus  is 
held  down  by  cicatrices  or  by  a  tumor.  Acute  pelvic  inflammation 
may  render  replacement  dangerous  or  impossible,  and  may  for  a  time 
contraindicate  all  direct  treatment.  Replacement  of  the  organs  from 
the  third  degree  of  prolapse  is  accomplished  in  the  inverse  order  of 
their  descent;  first,  the  posterior  vaginal  wall,  then  the  uterus,  and 
lastly  the  anterior  vaginal  wall.  Not  infrequently  the  completely  pro- 
lapsed uterus  and  pelvic  floor,  hernia-like,  become  strangulated.  Then 
taxis  usually  will  suffice;  but  it  may  have  to  be  supplemented  by  hot 
applications,  elastic  pressure,  anodynes,  and  the  knee-breast  position, 
and,  should  these  fail,  angesthesia. 

In  exceptional  cases  of  sudden  descent,  even  to  the  third  degree, 
replacement  alone  is  followed  sometimes  by  permanent  relief;  but 
if  the  descent  has  been  gradual,  it  always  occurs  immediately  after 
replacement.  Measures  are  required  therefore  for  the  maintenance 
of  the  uterus  in  the  normal  location  and  position.  This  indication  is 
fulfilled  by: 

Hygiene.  Pessaries. 

General  and  local  measures.  Surgical  operations. 

The  Hygiene  principally  relates  to  dress,  food,  exercise,  and  regular 
habit  of  the  bowels.  Undue  pressure  from  above  should,  if  possible, 
be  avoided.  The  clothing  should  be  loose,  and  the  weight  of  the  skirts 
supported  from  the  shoulders  either  by  straps  or,  preferably,  by  but- 
toning them  upon  a  waist  made  for  the  purpose.  The  waist  is  a  good 
substitute  for  the  corset,  which,  under  all  circumstances  and  in  all  forms, 
is  injurious.  Constipation  and  the  accumulation  of  feces  in  the  lower 
bowel  mechanically  irritate  and  may  displace  the  pelvic  organs;  strain- 
ing at  stool  exerts  downward  pressure  on  the  uterus  and  its  appendages. 
Careful  regulation  of  the  bowels  is  therefore  imperative;  to  this  purpose 
food  and  exercise  are  the  most  essential  agents. 

General  and  Local  Measures. — ^The  value  of  general  massage  for 
women  unable  to  take  active  exercise  is  very  great.  As  a  supplement 
to  massage,  or  as  an  independent  measure,  one  may  urge  strongly  the 
knee-breast  position.  This  position  assumed  several  times  a  day 
causes  the  uterus  to  gravitate  toward  the  diaphragm,  and  thereby  gives 
temporary  rest  to  the  overburdened  supports.  While  in  this  position 
the  patient  should  separate  the  labia  so  that  the  air  may  rush  in  and 
the  vagina  become  expanded.  jNIineral  waters  and  general  tonics  are 
useful.  The  measures  enumerated  above,  together  with  such  topical 
treatment  as  local  conditions  may  demand,  are  essential  as  adj^nants 
to  the  mechanical  or  surgical  treatment  which  almost  every  case 
requires. 


628  DISPLACEMENTS 

Pessaries. — In  the  genesis  of  retroversion  and  retroflexion  the  first 
change  is  descent;  hence,  the  principles  of  mechanical  treatment  must 
be  substantially  the  same  for  each.  The  reader  therefore  is  referred  to 
the  indications,  the  contraindications,  modes  of  adjustment,  and  uses 
of  pessaries  in  the  treatment  of  retroversion  and  retroflexion. 

In  complete  prolapse  dependent  upon  extensive  injury  of  the  perineum 
and  other  parts  of  the  pelvic  floor,  and  associated  with  subinvolution 
and  relaxation  of  all  the  pelvic  organs,  the  axis  of  the  vagina  is  changed 
from  its  forward  oblique  to  the  vertical  direction.  See  Figure  359. 
The  downward  traction  of  the  prolapsing  cystocele  and  rectocele  upon 
the  fornix  of  the  vagina  may  then  be  so  great  that  the  pessary-  is 
inadequate  to  maintain  in  place  the  upper  extremity  of  the  vagina. 
The  cervix  uteri  then  moves  forward,  the  corpus  turns  back,  and  the 
whole  uterus  easily  descends  in  a  vertical  direction  along  the  pro- 
lapsing walls  of  the  vagina  to  the  second  or  third  degree  of  prolapse. 
In  this  condition  pessaries  that  disappear  within  the  vagina  are  liable 
to  be  forced  out  with  the  prolapsing  pelvic  floor,  or,  if  retained,  seldom 
maintain  the  uterus  in  position.  In  such  cases  the  various  cup  pessaries, 
that  are  supplied  with  external  attachments  and  abdominal  belts, 
often  are  used;  but  they  either  so  fix  the  uterus  as  to  prevent  its  normal 
movements,  or  hold  it  in  such  unstable  equilibrium  that  it  may  assume 
any  one  of  the  various  malpositions — anterior,  posterior,  or  lateral; 
they  are  open  to  the  further  serious  objection  of  constantly  reminding 
the  patient  of  their  presence,  and  for  these  reasons  are  not  generally 
approved;  they  are,  however,  permissible  in  cases  of  complete  prolapse 
when  the  patient  refuses  surgical  relief.  As  an  expedient,  the  uterus 
sometimes  may  be  held  within  the  pelvis  by  means  of  a  large  Albert- 
Smith  pessary,  with  extreme  uterine  and  pubic  curves;  see  Application 
of  Pessaries  in  the  Treatment  of  Retroversion. 

Surgical  Treatment 

The  surgical  treatment  may  be  removal  of  the  uterus  by  hysterec- 
tomy, or  the  retention  of  it  in  its  normal  position  and  location  by  means 
of  plastic  operations. 

Hysterectomy. — The  failure  of  the  older  plastic  operations  to  hold 
the  uterus  in  place  permanently  has  induced  many  surgeons  to  adopt 


Explanation  of  Figure  359. 

A.  Incisions  have  been  made  from  the  posterior  vaginal  fornix  to  the  cul-de-sac  of  Douglas  and 
from  the  anterior  vaginal  fornix  to  the  uterovesical  cul-de-sac.  The  uterine  and  ovarian  arteries  in 
both  ligaments  have  been  securely  Ugated.  The  left  ligament  has  been  cut  away  from  the  uterus  and 
is  drawn  to  the  vulva  and  held  by  forceps.  The  uterus  has  been  drawn  through  the  vulva  and  is  hang- 
ing by  a  shred  to  the  right  ligament,  from  which  it  is  being  cut  away.  The  wound  made  bj'  the  removal 
of  the  uterus  with  its  peritoneal  and  vaginal  margins  shows  between  the  ligaments. 

B.  The  last  stitch  of  a  continuous  catgut  suture  is  being  taken  to  unite  the  peritoneal  margins  of 
the  wound.  The  line  of  suture  thus  made  runs  from  one  hgament  to  the  other  and  at  either  end  includes 
the  Ugament.     Closure  of  the  peritoneum  as  here  shown  is  nearly  complete. 

C.  The  ends  of  the  broad  ligament  are  shown  to  be  united  below  the  peritoneum  by  means  of 
a  continuous  catgut  suture.  Another  suture  is  closing  the  vaginal  margins  of  the  wound  by  a  line  of 
union  running  across  the  upper  end  of  the  vagina  from  side  to  side.  When  this  suture  is  complete, 
the  united  broad  ligaments  will  lie  between  peritoneum  and  vaginal  wall,  and  must  necessarily  sustain 
the  rectum,  vagina,  and  bladder  on  the  health  level. 


MAL-LOCATIONS  OF  THE  UTERUS 

FiGCKE  35'J 


(329 


630  DISPLACEMENTS 

the  more  radical  operation  of  vaginal  hysterectomy — a  permissible 
operation  on  women  who  have  passed  the  menopause,  but  usually  not 
permissible  during  the  child-bearing  period.  Cases  are  numerous  in 
which,  after  vaginal  hysterectomy,  the  pelvic  floor,  and  with  it  the 
rectum,  vagina,  and  bladder,  have  protruded  again  through  the  vulva. 
For  this  reason  the  operation  always  should  include  anchorage  of  the 
upper  end  of  the  vagina  to  its  normal  location  by  end-to-end  approxi- 
mation of  the  severed  broad  ligaments  in  the  wound  made  by  the 
removal  of  the  uterus.     See  Figure  359. 

Plastic  Operations. — The  rational  treatment  for  complete  prolapse 
requires:  first,  an  operation  on  the  anterior  vaginal  wall  to  restore  the 
upper  end  of  the  vagina  and  with  it  the  attached  cervix  to  their  normal 
place  in  the  hollow  of  the  sacrum;  second,  an  operation  at  the  vagi- 
nal outlet  to  bring  the  posterior  vaginal  wall  well  in  contact  with  the 
anterior  and  thereby  to  restore  the  lower  extremity  of  the  vagina, 
together  with  the  perineum,  to  its  normal  place  under  the  pubis.  The 
numerous  plastic  operations  on  the  anterovaginal  wall  for  the  relief 
of  complete  descent  of  the  uterus  are  divisible  into  two  classes: 

1.  Narrowing  the  Vagina. 

2.  Changing  the  Direction  of  the  Vagina. 

1.  Operations  designed  to  hold  the  uterus  up  by  narrowing  the  vagina 
so  much  that  the  litems,  not  being  able  to  pass  through  it,  must 
be  maintained  somewhere  in  the  pelvis  above  the  vaginal  constriction, 
usually  consist  in  the  removal  of  an  elliptical  piece  from  the  anterior 
or  posterior  wall  of  the  vagina,  or  from  both;  or  of  making  longitudinal 
denudations  and  bringing  the  edges  of  the  exposed  surfaces  together 
from  side  to  side.  In  this  class  of  operations  no  effort  is  made  to 
restore  the  normal  axes  of  the  uterus  or  the  vagina.  The  whole  purpose 
of  this  objectionable  operation  is  to  make  the  vagina  so  narrow  that 
the  uterus  cannot  pass  through  it.  Operations  of  this  class  generally 
fail,  because  they  do  not  restore  the  normal  angle  between  the  uterus 
and  the  vagina.  The  constricted  vagina,  indicated  by  the  white  lines 
in  Figure  361,  cannot  resist  the  downward  force  of  the  uterus,  which 
almost  invariably  dilates  the  vagina  a  second  time,  forces  itself  through, 
and  reproduces  the  hernia.  Moreover,  the  operation  does  permanent 
harm,  because  it  shortens  the  vagina,  thereby  making  it  draw  the  cervix 
away  from  the  sacrum  toward  the  pubes.  This  forward  movement  of 
the  cervix,  as  already  stated,  is  an  element  in  the  genesis  of  descent, 
and  therefore  should  not  be  employed  in  the  treatment  of  it. 

2.  Operations  designed  to  hold  the  uterus  in  position  by  restoring  the 
normal  aiigle  between  the  long  axis  of  the  uterus  and  the  long  axis  of  the 
vagina  may  narrow  somewhat  the  vagina,  but  such  narrowing  is  only 
an  incident  rather  to  be  regretted  than  desired.  It  is  not  essential  to 
the  success  of  the  operation. 

There  are  two  rational  indications:  first,  to  fix  the  upper  extremity 
of  the  vagina  together  with  the  cervix  uteri  in  its  normal  location 
within  an  inch  of  the  junction  of  the  second  and  third  sacral  verte- 
brse,  just  where  the  uterosacral  ligaments  would  hold  it  if  their  normal 


MAL-LOCATIOXS  OF  THE  UTERUS 


631 


tonicity  and  integrity  could  be  restored;  second,  to  bring  the  lower 

extremity  of  the  vagina  forward,  so  that  its  posterior  wall  shall  be  close 
up  against  the  puhes.  The  fulfilment  of  these  two  indications  will 
restore  the  normal  ol)liquity  to  the  vagina,  and  will  hold  the  cervix 
so  far  back  toward  the  sacrum  that  the  corpus  uteri  cannot  retrovert 
or  prolapse,  but  must  be  directed  forward  in  its  normal  anteverted 
position  of  mobile  equilibrium.  In  this  way  the  long  axis  of  the  uterus 
and  the  long  axis  of  the  vagina  will  form  an  acute  angle.  The  indications 
are  fulfilled  best  hy  elytrorrhaphy,  including  end-to-end  approximation 
of  the  cut  ends  of  the  broad  ligaments,  and  perineorrhaphy. 

Figure  360 


Uterus  in  line  with  the  vagina;  first  degree  of  descent.     The  white  Unes  in  the  vagina  show  where  it 
would  be  narrowed  by  the  first  class  of  operations. 


Re^^lolds  wisely  says:  "The  first  point  is — that  to  attain  success 
we  should  ascertain  and  utilize  the  natural  supports  of  the  anterior 
wall  instead  of  simply  denuding  and  gathering  together  the  over- 
stretched portions.  The  second,  that  we  should  not  only  avoid  using 
any  part  of  the  overstretched  portion  of  the  wall,  but  should  actually 
excise  and  do  away  with  it;  both  of  which  objects  should  be  attained 
■u'ithout  the  performance  of  an  unnecessarily  extensive  or  se\-ere 
operation. 

"The  mechanics  of  pehnc  support  are  after  many  years  still  the 
subject  of  dispute,  but  a  few  points  are  clear.     The  anterior  vaginal 


632  DISPLACEMENTS 

wall  has  naturally  two  fixed  points  of  attachment.  The  first  is  that 
of  the  lower  end  of  the  wall  to  the  posterior  surface  of  the  pubes.  This 
is  exceedingly  firm  and  never  yields.  The  same  cannot  be  said  of  the 
attachments  of  the  upper  end  of  the  wall;  they  are,  however,  sufficient 
for  the  purpose.  In  prolapse  complicated  by  cystocele,  the  correction 
of  the  cystocele  is  essential  to  the  cure  of  the  prolapse.  Our  experience 
of  late  years  in  total  extirpation  of  the  uterus  has  taught  us  that  the 
only  attachment  between  the  genital  canal  and  the  pelvic  wall,  which 
is  not  readily  separated  with  the  finger,  is  the  insertion  of  the  broad 
ligaments  into  the  lateral  edges  of  the  uterus  and  the  vault  of  the 
vagina.  These  the  only  firm  supports  of  the  vaginal  vault  furnish, 
then,  the  only  upper  points  which  rationally  can  be  used  in  the  restora- 
tion of  the  anterior  wall.  The  utilization  of  the  bases  of  the  broad 
ligaments  has,  moreover,  the  very  great  incidental  advantage  that  it 
not  only  relieves  the  uterus  of  the  weight  of  the  prolapsed  anterior 
wall,  but  in  itself,  as  will  be  seen,  tends  to  restore  the  prolapse  by 
throwing  the  cervix  backward.  The  first  point  in  any  operation  then 
should  be  the  attachment  to  each  other  of  these  two  firm  portions  of 
the  wall." 

The  fact  that  vaginal  hysterectomy  commonly  results  in  holding 
up  the  pelvic  floor,  and  with  it  the  rectum,  vagina,  and  bladder,  is 
because  in  this  operation  the  broad  ligaments  usually  are  fixed  in  the 
vaginal  wound ;  hence  the  same  result  may  be  secured  by  similar  means, 
even  though  the  uterus  is  not  removed.  Reynolds  further  remarks 
somewhat  as  follows: 

"To  this  first  principle  of  utilization  of  the  broad  ligaments  should 
be  added  the  second  principle  of  excision  of  the  weakened  portion  of  the 
anterior  vaginal  wall.  The  wall  in  its  natural  condition  is  a  short,  firm, 
fascial  and  muscular  structure,  which  extends  from  its  origin  at  the  firm 
bases  of  the  broad  ligaments  to  its  still  firmer  pubic  attachment,  thus 
forming  one  of  the  strongest  supports  of  the  uterus  and  other  pelvic 
organs.  Look  now  at  its  condition  in  a  well-developed  cystocele, 
as  represented  by  Figure  361,  neglecting  the  diagrammatic  straight 
lines.  The  wall  is  overstretched  because  it  has  lost  its  elasticity,  has 
lost  its  power  of  resistance  to  further  stretching.  If  now  we  utilize 
for  repair  any  part  of  this  weakened  wall,  we  shall  have,  as  a  result, 
a  weak  scar,  which  is  necessarily  predisposed  to  further  stretching." 

"Cystocele  is  in  effect  hernia  of  the  bladder  through  the  muscular 
and  fascial  structures  of  the  anterior  wall  of  the  vagina;  hence  the 
second  principle  involved  in  dealing  with  it  is  essentially  that  which 
already  is  well  established  in  the  treatment  of  other  hernias.  It  has 
been  customary  to  treat  cystocele  by  denuding  the  vaginal  wall  of  its 
epithelium,  invaginating  the  protrusion,  and  stretching  the  denuded 
surfaces  together.  No  one  today  would  think  of  treating  any  other 
hernia  in  such  a  manner.  On  the  contrary,  we  are  accustomed  to 
treat  other  hernias  by  reducing  them  and  excising  the  sac  until  we 
lay  bare  strong,  firmly  attached  fascial  edges."  Such  should  be  the 
treatment  of  cystocele.    The  principle  as  set  forth  by  Reynolds  in  the 


MAL-LOVATIONS  OF   THE   L'TERCS 


G33 


above  quotation  lias  led  me  to  ahandon  my  previous  operations  for 
elytrorrliaphy  and  to  substitute  the  operation  about  to  be  described. 
Before  describing  the  proposed  operation  I  would  repeat  the  fact 
that  the  various  plastic  operations  on  the  vajjjinal  walls  (elytrorrhaphy) 
have  proved  so  unsatisfactory  that  many  surji;eons  are  inclined  to 
abandon  them  and  to  adopt  the  radical  measure  of  vafi;inal  hysterec- 
tomy in  their  place.  This  operation,  however,  if  performed  by  the 
familiar  method  of  ligating  the  broad  ligaments,  cutting  them  from  the 
uterus,  and  then  letting  them  retract  to  the  sides  of  the  pelvis,  is  in- 
adequate, because  the  ligaments  thus  retracted  cannot  perform  their 
functions  of  holding  up  the  pelvic  floor;  consequently,  many  hyster- 
ectomies performed  in  this  way  have  been  followed  by  a  continuance 


Figure  361 


The  line  X  Y  shows  the  direction  and  location  of  the  vesicovaginal  wall  to  be  restored.  The  light 
radiating  lines  at  X  suggest  the  lines  of  force  on  the  broad  ligaments  as  caught  up  by  sutures.  The 
pouching  vaginal  wall  between  -Y  and  Y  takes  the  form  of  extreme  cystocele. 


of  the  downward  displacement  of  the  rectum,  vagina,  and  bladder,  a 
condition  not  materially  improved  by  the  mere  absence  of  the  uterus. 
In  order  to  utilize  the  normal  supporting  power  of  the  ligaments,  I 
devised  and  in  1902  published  an  operation  by  which  the  several  liga- 
ments were  approximated  end  to  end  between  the  peritoneal  and  vaginal 
sides  of  the  wound  made  by  the  removal  of  the  uterus.  In  a  foregoing 
part  of  this  chapter  I  have  introduced  this  operation  unmodified,  because 
I  desire  to  make  use  of  the  principle  of  end-to-end  approximation  in 
the  surgical  treatment  of  complete  descent  of  the  uterus,  a  descrip- 
tion of  which  will  follow.  Figure  359  will  serve  to  illustrate  the  treat- 
ment of  the  broad  ligament  by  end-to-end  approximation  in  vaginal 
hysterectomy. 
39 


634  DISPLACEMENTS 

Elytrorrhaphy,  Including  End-to-end  Approximation  of  the  Broad 
Ligaments  and  Excision  of  the  Cystocele} — The  mechanism  of  descent 
would  suggest  at  once  shortening  of  the  uterosacral  hgaments  to  draw 
the  cervix  uteri  back  to  its  normal  location  near  the  hollow  of  the  sacrum, 
and  shortening  the  round  ligaments  to  draw  the  corpus  forward  so  as 
to  restore  the  normal  direction  of  the  uterine  axis.  These  procedures 
might  be  curative  in  cases  of  retroversion  or  retroflexion  without  great 
descent,  but  when  not  only  the  uterus,  but  also  the  whole  pelvic  floor, 
is  in  extreme  downward  hernial  displacement  the  uterosacral  and  round 
ligaments,  even  though  shortened,  do  not  have  sufficient  power  to  give 
permanent  support.  The  strain  on  them  is  so  great  that  they  are  apt 
to  stretch  out  and  permit  the  descent  to  recur.  Adequate  sustaining 
power  under  the  uterus  is  essential.  To  appreciate  the  part  which  the 
broad  ligaments  properly  may  have  in  a  correct  operation,  it  is  only 
necessary  to  observe  the  fact  that  vaginal  hysterectomy,  as  above 
described,  results  in  holding  up  the  pelvic  floor  and  with  it  the  rectum, 
vagina,  and  bladder,  because  in  this  operation  the  broad  ligaments 
are  fixed  to  the  vaginal  wound.  Since  the  condition  of  procidentia  is 
hernia  not  alone  of  the  uterus,  but  of  the  rectum,  vagina,  and  bladder 
as  well,  let  us  try  to  hold  up  the  pelvic  floor,  including  the  uterus,  by 
similar  means,  even  though  the  uterus  be  not  removed. 

Following  the  suggestion  of  Emmet,  Sims,  Reynolds,  and  others 
who  have  attempted  to  draw  structures  in  the  neighborhood  of  the 
lower  margins  of  the  ligaments  in  front  of  the  cervix  in  order  to  force 
it  back,  I  found  myself  stripping  the  structures  more  and  more  from 
the  side  of  the  uterus  and  drawing  them  in  front  of  it,  but  not  until 
I  actually  severed  a  considerable  portion  of  each  ligament  from  the  sides 
of  the  uterus  did  I  secure  the  best  results.  In  future  operations  I  shall 
emphasize  that  part  of  the  procedure  as  shown  in  the  drawings  more 
than  I  have  done  yet.  Figures  362  to  370  with  their  legends,  will 
illustrate  the  proposed  method  of  holding  up  not  only  the  uterus,  but 
also  the  rectum,  vagina,  and  bladder,  by  end-to-end  approximation 
of  the  broad  ligaments  and  adequate  excision  of  the  cystocele,  without 
removal  of  the  uterus. 

In  addition  to  approximation  of  ligaments,  it  must  be  borne  in  mind 
that  other  supporting  structures  are  brought  together  in  front  of  the 
cervix  uteri,  notably  the  adjacent  parametric  structures,  and  if  the 
operation  is  sufficiently  extensive,  also  the  round  ligaments.  In  extreme 
cases  it  would  be  well  to  separate  the  bladder  entirely  from  the  cervix 
uteri,  as  would  be  done  in  vaginal  section,  so  as  to  expose  the  round 
ligaments.  These  ligaments  then  could  be  brought  down  in  front  of 
the  cervix  and  included  in  the  sutures  which  are  used  to  approximate 
the  cut  ends  of  the  broad  ligaments.  Such  adjustment  of  the  broad 
and  round  ligaments,  together  with  adjacent  parametria  in  front  of 
the  cervix,  necessarily  would  give  great  strength  to  the  pelvic  floor. 

The  question  frequently  has  been  asked  whether  in  cutting  away 

1  Read  in  the  Section  on  Obstetrics  and  Diseases  of  Women  of  the  American  Medical  Association, 
at  Boston,  June,  1906. 


MAL-LOCATIONS  OF  THE   UTERUS  635 

the  lower  halves  of  the  broad  ligaments  troublesome  hemorrhage  is  not 
encountered.  I  should  fear  such  hemorrhage  if  the  ligaments  were 
severed  with  the  uterus  in  its  normal  location,  but  would  not  fear  it 
with  the  uterus  outside  the  body.  Besides,  since  a  shaN'ing  is  removed 
from  each  side  of  the  uterus,  the  incision  usually  would  be  safely  in- 
side the  utero-ovarian  anastomosis.  At  any  rate,  the  uterus  being 
outside  the  body,  hemorrhage  can  be  controlled  easily  if  it  does  occur. 

Even  at  the  risk  of  prolixity,  I  repeat  that  it  is  essential  to  remove 
the  entire  thickness  of  the  vaginal  layer  of  the  vesicovaginal  septum, 
as  shown  in  Figure  362.  The  illustrations  of  this  operation  here  show 
the  cervix  uteri  drawn  well  down  to  the  vulva,  bid  this  appearance 
is  itifroduccd  only  to  facilitate  the  illustration;  the  suturing  part  of  the 
operation  should  be  performed  so  far  as  possible  with  the  cervix  in  the 
hollow  of  the  sacrum  where  the  operation  is  designed  to  fix  it.  The 
incisions  may  be  made  with  the  uterus  drawn  down,  but  it  is  well  to 
introduce  the  sutures  with  the  cervix  uteri  in  place,  and  to  this  end  the 
left  lateroprone  position  and  Sims'  speculum  may  be  used  ad\-anta- 
geously.  The  author  uses  a  speculum  with  the  blade  perforated  at 
its  extreme  end,  and  before  the  speculum  is  introduced  the  cervix  is 
attached  to  the  end  of  the  blade  by  means  of  a  temporary  suture  which 
is  passed  through  the  posterior  lip  of  the  cervix  and  then  through  the 
perforation  in  the  speculum,  and  tied.  This  temporary  stitch,  while 
the  sutures  are  being  applied,  holds  the  cervix  far  back  in  the  hollow 
of  the  sacrum;  it  should  be  removed  at  the  end  of  the  operation.  When 
the  cervix  thus  is  held  back,  the  space  anterior  to  the  uterus  is  so  in- 
creased that  the  uterus  readily  falls  forward  into  a  position  of  decided 
anteversion  and  shows  the  advantage  of  doing  the  operation  mth  the 
organ  in  normal  position. 

Contraindication  to  Elytrorrhaphy. — Elytrorrhaphy  is  usually  un- 
necessary and  therefore  contraindicated  in  descent  of  the  first  degree. 
The  special  province  of  the  operation  is  in  complete  prolapse  or  pro- 
cidentia ivhen  associated  with  cystocele.  The  operation  further  is  con- 
traindicated by  tumors  and  adhesions  which  render  replacement  and 
retention  impossible,  and  in  diseases  of  the  uterus  or  its  appendages 
which  demand  their  removal.  ^Vhen  such  contraindications  do  not 
exist,  unless  the  descent  is  extreme,  elytrorrhaphy  and  perineorrhaphy 
are,  usually  at  least,  quite  as  effective,  and  are  therefore  to  be  pre- 
ferred to  the  more  dangerous  and  mutilating  hysterectomy. 

Perineorrhaphy. — As  already  stated,  it  is  most  important  to  appre- 
ciate the  fact  that  in  nearly  every  case  of  procidentia  the  lower  extremity 
of  the  vagina  is  displaced  back^^ard.  This  is  consequent  upon  subin- 
volution of  the  vaginal  walls,  and  especially  upon  subinvolution  or 
rupture  of  the  perineum  or  of  some  other  portion  of  the  vaginal  outlet. 
Unless,  therefore,  the  posterior  wall  of  the  vagina  and  the  perineum 
can  be  brought  forward  to  their  normal  location  under  the  pubes, 
so  as  to  give  support  to  the  anterior  vaginal  wall,  the  latter  will  fall 
again,  will  drag  the  uterus  after  it,  and  the  hernial  protrusion  will  be 
reproduced.     The  treatment,  therefore,  of  complete  procidentia  must 


636 


DISPLACEMENTS 

Figure  362 


Broad  ligament  operation  for  complete  descent  of  the  uterus.  Cervix  held  steady  by  flat  vulsellum 
forceps.  The  bladder  lies  in  front  of  the  prolapsed  uterus.  The  dotted  line  extending  in  the  median 
direction  on  the  anterior  wall  of  the  cervix  from  a  point  at  the  uterovaginal  attachment  to  the  urethro- 
vaginal wall,  marks  the  direction  of  an  incision  to  be  made  by  means  of  sharp-pointed  scissors  through 
the  vaginal  layer  of  the  vesicovaginal  septum.  The  incision  extending  around  the  anterior  half  of  the 
cervix  at  the  uterovaginal  attachment  is  made  through  the  vaginal  wall  to,  but  not  into,  uterine  tissue. 


FiQUUE  303 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  Bladder  being  stripped 
from  uterus  by  blunt  dissection,  which  is  accomplished  readily  and  quickly  by  sponge 
pressure,  and  is  continued  to  the  peritoneal  reflexion  of  the  vesico-uterine  pouch  precisely 
as  it  would  be  if  the  operator  were  going  to  open  into  the  peritoneal  cavity  between  the 
uterus  and  bladder.  Observe  here,  just  beneath  the  sponge,  the  translucent  peritoneum, 
which  for  the  present  purpose  is  not  usually  to  be  incised. 


637 


Figure  364 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  bladder  has  been 
stripped  from  the  uterus,  and  the  peritoneum  exposed  (Figure  357),  the  vesicovaginal  septum 
is  drawn  down  over  the  anterior  uterine  wall  hf  a  forceps,  and  the  vaginal  layer  of  the 
septum  is  being  split  on  the  median  line  with  scissors. 


638 


FiGunE  SC)") 


Broad  Ligament  Operation  for  Complete  Descent  of  tlie  Uterus.  The  vaginal  layer 
of  the  vesicovaginal  septum  is  being  stripped  away  from  the  bladder  wall  by  the  same  kind 
of  blunt  dissection  used  in  Figure  357.  The  bladder  as  it  is  separated  is  pushed  up  out  of 
sight. 


639 


FiGDRE    366 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  lower  two-thirds  of 
each  broad  ligament,  and,  to  avoid  wounding  the  utero-ovarian  anastomosis,  a  thin  shaving 
also  of  the  cervix  are  being  cut  away  with  sharp-pointed  scissors.  The  right  ligament  has 
been  severed  and  the  left  is  being  severed.  The  redundant  vaginal  layer  (cystocele)  which 
has  been  stripped  off  from  the  bladder  is  held  by  forceps  out  of  the  way  to  either  side. 


640 


FlOURE    ."JO? 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  severed  lower 
two-thirds  of  the  broad  Ugaments  are  being  approximated  end  to  end  by  catgut  sutures. 
First  suture  in  place  and  being  drawn  tight.  These  ends  as  they  are  drawn  together  already 
are  forcing  the  cervix  back.  As  already  explained,  the  cut  ends  of  these  ligaments  when 
united  pull  down  together  with  them  the  adjacent  parametric  structures  and  in  exten.sive 
operations  also  the  round  ligaments.  Too  tight  tying  is  apt  to  strangulate  the  tissues, 
cause  the  sutures  to  cut  out,  and  prevent  union.  No.  1  or  No.  2  chromic  catgut 
ordinarily  is  used.     Silkworm  gut  is  better,  but  difficult  to  remove. 


641 


Ftgure  3G8 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  lower  two-thirds 
of  the  severed  broad  ligaments  have  been  united  end  to  end  by  catgut  sutures,  thus  forcing 
the  cervix  still  farther  back.  The  redundant  vaginal  wall  (cystocele)  has  been  cut  away 
on  the  right  and  is  being  cut  away  on  the  left.  The  entire  thickness  of  the  vaginal  wall  is 
being  cut  away;  this  is  in  contrast  to  the  older  method  of  superficial  denudation. 


642 


KraoHE  309 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  severed  ends  of  the 
broad  ligamenthaving  been  united  in  front  of  the  cervix  and  the  cystocele  excised,  the  cut 
edges  of  the  vaginal  wall  are  being  approximated  from  side  to  side.  The  first  suture, 
which  is  being  drawn  tight,  shows  how  the  margins  are  approximated  near  the  cervix.  The 
other  sutures  show  the  method  of  union  between  this  first  suture  and  the  others,  which 
are  introduced  but  not  tied.  Observe  that  these  sutures  all  catch  up  the  uterine  wall, 
thus  forcing  the  bladder  up  so  that  it  cannot  come  down  again  between  the  uterus  and  the 
vagina.     This  forcing  up  the  bladder  is  a  very  essential  factor  in  the  success  of  the  operation. 


643 


Figure  370 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  redundant  vaginal 
wall  having  been  removed  (Figure  362)  the  lateral  margins  of  the  vaginal  wound  are  being 
united  by  interrupted  sutures.  As  the  result  of  this  union  the  cervix  and  upper  end  of 
the  vagina  have  been  forced  back  to  their  normal  location  in  the  hollow,  of  the  sacrum. 
B  and  C  show  the  lines  of  union  complete.  At  the  urethral  end  of  the  wound  the  redundant 
vaginal  wall  cannot  be  disposed  of  always  by  a  median  line  of  union.  It  may  be  necessary, 
as  shown  here,  to  unite  that  part  in  a  direction  at  the  right  angles  to  the  main  line  of  union. 
Traction  is  being  made  by  tenacula  at  each  end  of  this  transverse  line  of  union.  The  cervical 
lines  of  union  also  have  the  T-shape. 


644 


MAL-J.()('ATI().\S  OF   THE   UTERUS  ()45 

always  incliule  an  a(K'(iiuiti'  operation  \\\h>\\  the  j)criiic'um,  or,  more 
comprehensively  speakinij,  upon  the  posterior  wall  of  the  \afi;inal  outlet. 
The  operation  must  be  performed  so  that  it  will  carry  the  lower  ex- 
tremity of  the  vagina  forward  to  the  normal  location  close  up  under 
the  pubes;  then,  if  the  anterior  elytrorrhai)hy  is  adequate,  the  whole 
vagina  will  have  its  normal  oblique  direction,  and  its  long  axis  will 
make  an  acute  angle  to  the  long  axis  of  the  uterus.  When  this  angle 
is  maintained,  the  uterus  cannot  easily  turn  the  sharp  corner  which 
will  bring  its  long  axis  into  coincidence  with  that  of  the  vagina,  and 
cannot,  therefore,  readily  prolapse.     See  Chapter  on  Perineorrhaphy. 

Comparison  of  Eljrtrorrhaphy  and  Hysterectomy. — As  laid  down  in  the 
foregoing  paragraphs,  the  utilization  of  the  broad  ligaments  is  an  essen- 
tial factor  in  the  treatment  of  complete  procidentia.  The  operation 
of  elytrorrhaphy  abo\-e  described  unfortunately  either  may  fail  to  bring 
the  lower  edges  of  the  broad  ligaments  sufficiently  to  the  front  of  the 
uterus  to  enable  them  to  hold  up  the  uterus  and  vagina,  or  the  ligaments 
having  been  stitched  in  front  of  the  uterus  the  stitches  may  not  hold. 
Consequently  in  complete  procidentia  elytrorrhaphy  even  though 
well  performed  may  fail.  At  least  this  has  been  the  author's  experience 
in  a  number  of  cases.  Therefore  the  completely  prolapsed  uterus  may 
have  to  be  removed  in  order  to  anchor  absolutely  the  cut  ends  of  the 
broad  ligaments  to  the  upper  part  of  the  vagina.  As  before  stated, 
the  operation  should  include  the  treatment  of  the  hernial  factor  in  the 
lesion — that  is,  removal  of  the  redundant  portion  of  the  anterior  vaginal 
wall.     Generally  speaking,  the  indications  are  somewhat  as  follows: 

1.  Extreme  cystocele  not  associated  mth  complete  procidentia 
should  be  treated  by  elytrorrhaphy  and  perineorrhaphy. 

2.  Extreme  cystocele  associated  with  complete  procidentia  properly 
may  be  treated  by  hysterectomy,  elytrorrhaphy,  and  perineorrhaphy. 

3.  Conditions  intermediate  between  the  two  conditions  indicated 
above,  and  cases  of  very  feeble  or  very  aged  women,  will  call  for  special 
judgment  whether  hysterectomy  should  be  omitted  or  performed. 
It  is,  however,  a  fortunate  fact  that  the  completely  prolapsed  uterus 
even  in  aged  women  is  removed  usually  with  ease  and  with  safety. 

The  indication  for  perineorrhaphy  as  a  supplement  to  hysterectomy 
is  the  same  as  it  is  after  elytrorrhaphy.  After  the  senile  changes  of 
the  menopause,  vaginal  hysterectomy  for  obvious  reasons  is  relatively 
unobjectionable,  and  in  many  cases  may  be  preferred  to  elytrorrhaphy. 
In  connection  with  hysterectomy,  however,  the  removal  of  a  portion 
of  the  anterior  vaginal  wall  usually  will  be  required. 

Other  Operations  designed  to  decrease  the  weight  of  the  uterus 
by  removal  of  a  part  of  it  are  of  questionable  value.  The  treatment 
of  increased  weight,  due  to  subinvolution,  h\-pertrophy,  congestion, 
h\'perplasia,  and  tumors,  is  described  elsewhere  under  those  subjects. 

Amputation  of  the  cervix  to  lighten  the  weight  of  the  uterus  has 
been  practised  much  for  the  spurious  circular  hypertrophy  and  hyper- 
trophic elongation  shown  in  Figure  35S.  Since  these  two  conditions 
are  rare,  if  not  indeed  unknown,  it  follows  that  they  could  seldom 


646  DISPLACEMENTS 

furnish  an  indication  for  amputation  of  the  cervix  uteri.  It  is,  in 
fact,  difficult  to  imagine  a  class  of  cases  in  which  this  operation  would 
be  indicated.  Emmet's  explanation  of  the  pathology  of  this  class  of 
cases  has  led  to  the  substitution  of  trachelorrhaphy  or  of  Schroeder's 
operation  for  amputation  of  the  cervix. 

Tumors  increasing  the  weight  of  the  uterus  and  tumors  exerting 
pressure  from  above  or  traction  from  below  should,  if  practicable,  be 
removed. 

Alexander's  Operation  and  Abdominal  Hysterorrhaphy  are  described 
under  the  surgical  treatment  of  retroversion  and  retroflexion.  The 
object  of  these  operations  is  to  suspend  the  uterus  from  above.  Hys- 
terorrhaphy, which  fulfils  this  indication  better  than  shortening  the 
round  ligaments,  may  be  indicated  in  cases  of  extreme  relaxation  of 
the  uterine  supports  and  greatly  increased  weight  of  the  uterus.  The 
results  of  it  in  procidentia,  however,  will  usually  not  be  permanent 
unless  it  is  supplemented  by  elytrorrhaphy  and  perineorrhaphy. 


Enteroptosis  as  a  Complication  of  Descent  of  the  Uterus 

In  many  cases  of  descent  of  the  uterus  the  displacement  is  aggra- 
vated by  alterations  in  abdominal  pressure  associated  with  descent  of 
the  abdominal  viscera,  especially  the  stomach  and  intestine.  These 
conditions  are  gastroptosis  and  enteroptosis.  Webster  has  laid  stress 
upon  the  fact  that  general  weakness  and  laxity  of  the  abdominal  wall 
are  not,  as  usually  supposed,  the  cause  of  the  enteroptosis,  but  that 
descent  of  the  viscera  is  caused  by  excessive  separation  of  the  recti 
muscle,  due  to  stretching  of  the  linea  alba.  All  conditions  that  in- 
crease abdominal  pressure,  expecially  during  pregnancy,  such  as  the 
wearing  of  corsets  and  overwork,  predispose  to  enteroptosis.  Loss  of 
fat  is  also  a  cause  of  enteroptosis. 

An  operation  proposed  by  Webster  is  the  deliberate  opening  of  the 
abdomen  for  the  cure  of  enteroptosis.  It  is  much  the  same  as  that 
which  for  a  long  time  has  been  performed  for  the  relief  of  ventral 
hernia,  and  is  substantially  as  follows: 

An  incision  is  made  in  the  median  line,  dividing  the  skin  and  sub- 
cutaneous fat  until  the  linea  alba  is  exposed.  The  length  of  the  incision 
should  vary  with  the  extent  of  the  separation  of  the  recti  muscles. 
In  aggravated  cases  it  should  extend  from  the  symphysis  pubis  nearly 
to  the  ensiform  cartilage.  The  umbilicus,  if  deep  and  difficult  to  clean 
thoroughly,  should  be  removed;  otherwise  the  mesial  incision  may  be 
carried  around  to  the  left  of  it.  The  skin  and  fat  should  be  dissected 
from  the  fascia  on  both  sides,  so  as  to  expose  the  edge  of  each  rectus 
muscle.  The  sheath  of  each  muscle  is  then  split  longitudinally  along 
the  inner  border  and  the  incision  continued  to  the  extent  of  the  diastasis. 
The  inner  borders  of  the  muscles  are  then  loosened  from  the  sheaths 
and  united  by  a  series  of  chromic  catgut  sutures  passed  from  side  to 
side  through  each  muscle  and  the  corresponding  anterior  fascia  or  sheath 


MAL-LOCATIONS  OF   THE   UTERUS  047 

layer.  Tliese  sutures  wlien  tied  will  obliterate  the  stretched-out  linea 
alba,  ap])r()xiniate  the  uniscles  aud  e()\er  them  with  faseia.  Some 
bul^iug  of  tile  sis.iu  may  follow  the  reduction  in  the  size  of  the  inner 
abdominal  wall,  but  after  a  little  time  this  usually  disappears.  In 
cases  of  excessi\-e  relaxation  a  strip  of  fat  and  skin  may  be  removed 
before  passing  the  superficial  sutures.  The  use  of  a  broad  silk  elastic 
binder,  daily  massage  of  the  abdominal  parietes,  followed  later  by  light 
gymnastic  exercise  and  abstinence  from  severe  exertion  during  a  period 
of  six  months,  are  recommended  as  part  of  the  after-treatment. 


CHAPTER   XL 

MALPOSITIONS  OF  THE  UTERUS;  ETIOLOGY,  SY:MPT0MS, 
COURSE,  DIAGNOSIS,  AND  PROGNOSIS  OF  RETRO- 
VERSION AND   RETROFLEXION 


RETROVERSION 

Retroveesion  is  that  abnormal  position  of  the  uterus  in  which  the 
fundus  is  posterior  to  the  axis  of  the  pelvic  inlet.  If  the  cervix  be 
in  its  normal  place,  near  the  sacrum,  retroversion  is  scarcely  possible, 
because  prevented  by  the  proximity  of  the  overarching  sacrum. 
The  first  degree  of  prolapse  must,  usually,  precede  any  considerable 
backw^ard  turning  of  the  uterus.  When  the  cervix  has  been  displaced 
downward  and  forward  so  far  that  its  distance  from  the  sacrum  is  equal 
to  or  greater  than  the  length  of  the  uterus,  retroversion  to  any  extent 
becomes  possible. 

Etiology  and  Description  of  Retroversion 

From  the  above  it  follows  that  the  causes  of  beginning  retrover- 
sion must  be  identical  with  the  causes  of  the  first  degree  of  prolapse. 
After  the  puerperium  the  relaxation  of  the  supports  and  the  weight  of 
the  displaced  organ  may  persist,  and  this,  together  with  the  pressure 
and  weight  of  the  intestine  upon  the  anterior  surfaces  of  the  uterus, 
may  prevent  spontaneous  replacement.  Every  act  of  defecation  forces 
the  cervix  forward  and  downward,  and  the  uterus,  being  in  the  axis 
of  the  vagina,  and  having,  therefore,  little  support  below,  must  depend 
for  support  upon  the  now  inadequate  subinvoluted  peritoneal  suspen- 
sory ligaments  and  pelvic  fascia.  Abortion,  with  resulting  increased 
weight  and  relaxation  of  the  vaginal  walls,  is  a  common  cause  of  descent. 
^Metritis,  parametritis,  perimetritis,  peritonitis,  salpingitis,  and  ovaritis 
are  frequent  complications,  and  may  stand  in  the  relation  of  cause 
or  effect. 

Congenital  retroversion  is  rare.  Retroposition  of  the  small  senile 
uterus  after  the  menopause  is  not  abnormal.  Peritoneal  adhesions 
and  cicatricial  bands  may  fix  permanently  the  corpus  in  a  retroverted 
position.  In  extreme  retroversion  the  corpus  often  is  incarcerated 
between  the  uterosacral  ligaments  under  the  promontory  of  the  sacrum. 
Chronic  cystitis  and  consequent  contraction  of  the  bladder  shorten 
the  vesicovaginal  wall,  and  thereby  draw  the  cervix  forward.  This 
makes  a  permanent  incurable  displacement. 
(648) 


RETROVERSION  AND  RETROFLEXION 


649 


The  causes  of  retroversion  may  he  summarized  as  follows: 

1.  Distension  of  the  hhidder. 

2.  Inereased  weij^ht  of  the  uterus  and  rt-hixation  of  the  supports 

— eommon  cause  in  early  puerperium. 

3.  Retro-uterine  peritonitis — contracting  adhesions. 

4.  Sudden  straining,  violent  fall,  or  blow — rare. 

5.  Chronic  cystitis,  which  shortens  the  vesicovaginal  septum  by 

contraction — an  intractable  cause. 

6.  Small  myoma  in  posterior  wall  of  the  corpus  uteri. 

7.  The  dorsal  position  and  tight  bandaging  in  the  puerperium. 

8.  Congenital — rare. 


Figure  371 


Retroversion. 


Symptoms  and  Course  of  Retroversion 

The  displacement  of  retroversion  and  its  numerous  complications 
usually  cause  bearing-down  sensations,  a  feeling  of  heaviness  in  the 
pelvis,  exhaustion  upon  walking  and  standing,  especially  the  latter. 
Constipation  may  be  a  cause  or  an  effect.  After  the  puerperium  the 
extreme  engorgement  of  the  peh'ic  organs  often  contributes  to  hemor- 
rhagic endometritis.  The  hemorrhage  then  shoidd  not  be  confounded 
with  returning  menstruation.  The  bleeding,  especially  after  abortion, 
unless  relieved  by  treatment,  often  persists  for  a  long  time.  Gradual 
or   sudden   replacement    may    occur    spontaneously;    or,    the    causes 


650 


DISPLACEMENTS 


continuing  active,  the  displacement  may  persist  and  even  be  reinforced 
by  cystocele  and  rectocele.  There  is  usually  concurrent  displacement 
of  the  ovaries  and  Fallopian  tubes.  Nutritive  changes  in  the  uterine 
walls  may  induce  a  superadded  retroflexion.  The  heavy  organ  may 
descend  along  the  relaxed,  subinvoluted  vaginal  walls  even  to  com- 
plete procidentia. 


Diagnosis  and  Prognosis  of  Retroversion 

The  symptoms  indicate  the  probability  of  displacement,  but  definite 
diagnosis  depends  upon  direct  examination.     Conjoined  manipulation 

Figure  372 


Degrees  of  retroversion.^ 

will  usually  establish  the  diagnosis  and  show  the  organ  retroverted, 
with  the  cervix  displaced  toward  the  pubes  and  with  the  corpus  in 
the  hollow  of  the  sacrum.  In  certain  cases  of  anteflexion,  as  repre- 
sented in  the  chapter  on  that  subject,  the  cervix  is  bent  forward  in 
the  vaginal  axis  as  in  retroversion.  The  condition  is  in  reality  one  of 
retroversion  of  the  cervix,  with  high  anteflexion  of  the  corpus.  Under 
treatment,  the  prognosis,  both  for  speedy  relief  and  ultimate  recovery, 
is  generally  favorable. 

^  Suggested  by  Penrose.     Diseases  of  Women. 


RETROVERSION  AND  RETROFLEXION 


651 


Degrees  of  Retroversion 

Retroversion  will  be  slight  or  extreme  according  to  the  extent  to 
which  the  axis  of  the  uterus  is  turned  back.  Three  degrees  of  dis- 
placement usually  are  recognized;  but  the  division  is  arbitrary,  and, 
except  for  purposes  of  description,  has  no  practical  significance.  See 
Figure  372. 

Treatment  of  Retroversion 

The  treatment,  as  in  descent,  consists  of  the  removal  of  the  inflam- 
matory and  other  complications,  in  the  use  of  pessaries,  and  in  surgical 
operations.  Inasmuch  as  the  treatment  is  similar  to  that  of  retroflexion, 
the  treatment  of  retroversion  and  retroflexion  will  be  presented  together 
in  the  following  chapter. 

Figure  373 


Extreme  retroflexion  with  hypertrophy  of  the  corpus  uteri.     The  uterus  impinges  on  and 
compresses  the  rectum. 


RETROFLEXION 


Retroflexion  is  that  displacement  in  which  the  organ  is  bent  back  upon 
itself.  It  usually,  though  not  always,  results  from,  and  is  associated 
Vl^th,  retroversion ;  in  accordance  with  custom,  the  double  displacement 
will  be  termed  retroflexion. 


652        ,  DISPLACEMENTS 

Etiology  and  Pathology  of  Retroflexion 

The  causes  of  retroflexion  are  identical  with  those  of  retroversion, 
which  to  a  very  great  extent  may  be  summarized  as  follows : 

1.  All  causes  of  retroversion.    See  Descent  and  Retroversion. 

2.  The  dorsal  position  and  tight  bandaging  in  the  puerperium. 

3.  Tight-lacing  and  tight  clothing. 

4.  An  infectious  puerperium  impairing  the  nutrition  of  the  uterine 

walls  and  uterine  supports. 

5.  Pressure  by  tumors. 

6.  Congenital  conditions — rare  and  usually  associated  with  under- 

development of  the  other  reproductive  organs. 

7.  Great  weight  of  the  corpus  uteri. 

8.  Soft  mobile  condition  of  the  uterine  walls — common  during 

the  puerperium. 

9.  Intra-abdominal   forces,    such    as    downward    pressure   during 

defecation. 
10.  Metritis  and  perimetritis,  especially  when  associated  with  post- 
uterine  adhesions. 
The  ovaries  and  Fallopian  tubes,  unless  fixed  elsewhere  by  adhesions, 
are  held  down  usually  on  either  side  of  the  corpus  uteri.     They  are 
sometimes  much  enlarged  by  inflammation,  often  adherent,  and  always 
extremely  sensitive.     Infection  of  the  uterus  and  its  appendages  from 
bacterial  invasion  is  almost  invariably  the  essential  cause.     The  dis- 
placement often  follows  parturition,  abortion,  and  injudicious  treat- 
ment.    Gonorrhoea  and  the  puerperal  infections  are  frequent  causes. 
Peritoneal  adhesions  between  the  corpus  uteri  and  the  pouch  of  Douglas 
may  render  replacement  impossible,  except  by  abdominal  or  vaginal 
section. 

Symptoms  and  Course  of  Retroflexion 

In  some  cases  there  are  no  subjective  symptoms.  The  conditions 
frequently  associated  with  retroflexion  are  these: 

1.  Sterility  and  frequent  abortion. 

2.  Uterine  discharges — leucorrhoea. 

3.  Menstrual     disorders — dysmenorrhoea,     amenorrhoea,     uterine 

hemorrhages. 

4.  Constipation  and  painful  defecation. 

5.  Bladder  disturbances. 

6.  Weakness  in  the  back  and  dragging  sensation  in  the  pelvis. 
Uterine  discharges,  menorrhagia,  and  abortion  usually  are  the  result 

of  associated  endometritis,  and  are  due  to  the  effort  of  an  engorged 
uterus  to  relieve  itself  of  congestion  by  increased  secretions  or  increased 
menstruation. 

Abortion,  dysmenorrhoea,  and  sterility  may  result  from  a  "^ade 
range  of  associated  conditions,  chief  among  them  faulty  nutrition, 
inflammatory  complications,  and  mechanical  obstruction  in  the  uterine 
canal  at  the  angle  of  flexure.    The  rectal  symptoms  are  caused  by  the 


RETROVERSIOX  AM)   RETROFLEXION  653 

proximity  of  the  inflamed  uterus,  and  its  aj)pendaf;es,  to  tlie  l)o\vel. 
This  ^ives  to  the  patient  the  sensation  of  a  full  bowel,  and  is  there- 
fore a  cause  of  tenesmus.  Passage  of  the  bowel-contents  throuj^h 
this  sensitive  zone  is  necessarily  painful.  Abdominal  j)ains,  nervous 
dyspepsia,  neuralgia  in  distant  parts  of  the  body,  and  neurasthenia 
are  often  present;  indeed,  the  nervous  symptoms  may  be  of  the  most 
exagf^erated  character,  and  may  comprise  all  that  is  implied  by  the 
word  hysteria  in  its  most  comprehensi\e  signification. 

Should  pregnancy  occur,  the  rapid  growth  of  the  uterus  may  induce 
spontaneous  reposition;  this  is  likely  to  take  place  when  the  fundus 
rises  out  of  the  pelvis  at  about  the  fourth  month;  but  if  the  corpus 
be  incarcerated  under  the  sacral  promontory  from  adhesions  or  from 
any  other  cause,  the  uterus,  unless  manually  replaced,  will  relieve  itself 
by  a  dangerous  abortion. 

Diagnosis  of  Retroflexion 

The  diagnosis  should  include  especially  an  inquiry  into: 

1.  The  location  and  position  of  the  uterus  relative  to  neighboring 

organs. 

2.  The  mobility  of  the  uterus. 

3.  The  complications. 

Digital  touch  discloses  the  cervix  uteri  low  in  the  pelvis.  The  fundus 
uteri  is  felt  through  the  posterior  vaginal  wall  in  the  cul-de-sac  of 
Douglas.  Conjoined  manipulation  with  the  index-finger  of  the  left 
hand,  first  in  the  vagina,  then  in  the  rectum,  and  the  right  hand  over 
the  hx-pogastric  region,  will  show  the  size,  form,  consistence,  and  loca- 
tion of  the  uterus,  the  degree  of  flexion,  and  the  difficulty  of  replace- 
ment. An  inflammatory  deposit  or  abscess  posterior  to  the  uterus, 
or  a  fibroid  in  the  posterior  uterine  wall,  may  be  mistaken  for  the 
retroflexed  corpus.  The  probe  is  seldom  necessary  to  verify  the  diag- 
nosis. It  should  be  vised  under  strict  antiseptic  conditions,  for  other- 
^\'ise  additional  infection  may  be  introduced.  In  some  cases  of  difficult 
diagnosis  it  is  better  at  first  to  direct  the  treatment  to  the  inflammation 
and  defer  the  precise  diagnosis  of  the  displacement  to  a  later  date. 
Great  and  lasting  injury  may  be  wrought  in  the  attempt  to  complete 
the  diagnosis  at  the  first  examination.  The  presence  of  a  small  myoma 
in  the  posterior  uterine  wall,  with  post-uterine  inflammation,  is  a  serious 
complication  both  in  diagnosis  and  treatment.  If  the  rectum  be  loaded 
with  fecal  matter,  a  cathartic  should  be  given  and  the  complete  digital 
examination  deferred.  The  displacement  is  distinguished  from  the 
presence  of  an  ovary  or  small  ovarian  tumor  in  the  pouch  of  Douglas, 
by  careful  bimanual  examination  and  by  the  probe. 

Diagnosis  in  the  Puerperium. — Uterine  hemorrhage  which  begins 
two  or  three  weeks  after  labor,  and  small  daily  losses  of  blood  during 
the  puerperium,  are  evidences  though  not  proof  of  retrodisplacement. 

Diagnosis  of  Complications. — The  following  complications  may  have 
the  relation  either  of  cause  or  eft'ect  to  the  displacement : 


654  DISPLACEMENTS 

1.  Perimetritic  fixation — result  of  perimetritis — is  recognized  by 
bands  of  adhesions  palpated  behind  and  to  the  sides  of  the  uterus 
and  felt  about  the  corpus  above  the  plane  of  the  internal  os,  near  the 
fundus.  Perimetritic  adhesions  commonly  fix  the  uterus  to  the  tubes, 
ovaries,  or  broad  ligaments,  and  such  adhesions  form  a  mass  recognized 
by  conjoined  palpation. 

2.  Parametritic  fixation — result  of  parametritic  cellulitis — extends 
more  usually  below  the  plane  of  the  os  internum;  it  draws  the  cervix 
laterally,  anteriorly,  or  posteriorly  toward  the  pelvic  wall  by  contrac- 
tion of  inflamed  cellular  tissue,  which  is  thicker  and  more  dense  than 
in  perimetritic  adhesions,  and  lower  in  the  pelvis. 

Differential  Diagnosis  of  Retroflexion 

The  differential  diagnosis  should  include  a  consideration  of  inflam- 
matory retro-uterine  masses,  retro-uterine  myomata,  hsematocele,  and 
fecal  accumulations. 

Retro-uterine  inflammatory  products  and  myomata  in  the  posterior 
wall  of  the  uterus  may  be  recognized  by  the  location  of  the  fundus 
uteri  lying  in  front  of  the  mass.    Examination  should  be  made  by: 
a.  Conjoined  palpation  with  or  without  narcosis. 
6.  The  uterine  sound — ^used  with  caution, 
c.  Conjoined  rectal  touch — most  important. 
The  tumor,  whether  inflammatory,  myomatous,  or  hsemic,  is  usually 
wider  than  the  uterus,  often  not  situated  directly  behind  the  cervix, 
but  to  one  side,  and  may  be  irregular  in  outline.    The  contrary  is  true 
of  the  retroflexed  corpus  uteri. 

Fecal  accumulations  may  be  excluded  by  cathartics. 


CHAPTER  XLI 

TREATISIENT  OF  RETROVERSION  AND  RETROFLEXION 

The  objects  of  treatment  are  replacement  and  retention  of  the 
uterus. 

Obstacles  to  Replacement 

The  obstacles  to  replacement  are  tumors,  inflammation,  and  fixa- 
tion of  the  uterus.  The  inflammatory  complications  often  require 
weeks,  and  in  severe  cases  months,  of  treatment  preparatory  to  replace- 
ment; not  uncommonly  a  tumor  must  be  removed  by  a  surgical  opera- 
tion. Some  of  the  general  therapeutic  suggestions  under  the  subject 
of  descent  are  also  applicable  to  retropositions.  Thus  rest,  massage, 
careful  regulation  of  the  bowels,  forced  feeding,  and  general  tonics 
may  be  essential. 

For  pelvic  inflammation,  small  blisters  over  the  inguinal  regions, 
frequently  repeated,  and  the  daily  application  of  a  cotton  and  glycerin 
tampon  to  the  cervix,  are  common  routine  measures  of  some  value. 
The  most  useful  and  essential  topical  application  is  the  hot-water 
vaginal  douche.  The  proper  manner  of  giving  the  douche  is  described 
in  Chapter  IV. 

As  the  tenderness  disappears  the  cotton  tampons  may  be  increased 
in  quantity,  and  thereby  made"  to  serve  as  temporary  support  for  the 
uterus  until  the  more  permanent  pessary  can  possibly  be  substituted. 
The  sluggish  circulation  in  the  pelvis  and  torpid  condition  of  the  bowels 
may  be  much  relieved  by  the  daily  application  of  the  hot  hip-pack; 
it  is  applied  as  follows: 

A  small  flannel  sheet,  folded  lengthwise  to  the  width  of  two  feet, 
dipped  in  very  hot  water  and  dried  by  passing  it  through  a  wringer, 
is  wound  about  the  hips  and  covered  by  another  dry  one.  At  the  end 
of  half  an  hour,  during  which  time  the  patient  maintains  the  recumbent 
position,  the  sheets  are  removed.  Hot-water  bags  between  the  wet  and 
the  dry  sheet  will  serve  to  prolong  the  heat. 

When  the  tenderness  has  been  sufficiently  reduced,  gentle  attempts 
at  replacement  may  be  made  every  day  or  two  by  conjoined  manipula- 
tion. The  patient's  tolerance  of  manipulation  may  thus  be  observed 
and  the  way  prepared  for  complete  replacement  and  permanent  reten- 
tion after  subsidence  of  the  inflammation. 

Fixation  and  tenderness,  until  overcome  by  appropriate  treatment, 
are  contraindications  to  replacement. 

(655) 


656  DISPLACEMENTS 

Methods  of  Replacement 

Manipulation.  —  Diseased  adnexse,  especially  salpingitis,  contra- 
indicate  forcible  manipulations  of  the  peh'ic  organs.  The  dangers 
incident  to  stretching  or  breaking  adhesions  or  contractions  are  very 
great  unless  the  manipulator  possesses  unusual  diagnostic  and  manual 
skill.  The  safest  and  most  effective  method  of  replacement  is  by  con- 
joined manipulations,  as  shown  in  the  following  illustrations.  Efficient 
reposition  of  the  uterus  is  very  often  impossible  without  anaesthesia. 
This  is  especially  true  when  the  corpus  is  wedged  in  and  incarcerated 
between  the  uterosacral  ligaments  under  the  sacral  promontory,  a 
condition  often  mistaken  for  displacement  with  adhesions. 

The  replacement  is  not  usually  accomplished  by  drawing  the  fundus 
directly  forward  and  pushing  the  cervix  back  directly  in  the  median 
line,  but  in  most  cases  by  sweeping  the  fundus  around  the  arc  of  a 
circle  on  the  left  side  of  the  pelvis  and  the  cervix  on  the  right.  This 
is  owing  to  the  greater  frequency  of  infection  on  the  left  side,  and 
consequent  shortening  of  the  left  broad  ligament.  After  replacement 
the  organ  is  to  be  held  in  position  by  appropriate  means. 

Bimanual  replacement  has  three  great  advantages  over  the  more 
familiar  methods  of  the  sound  or  repositor:  first,  it  is  more  effective 
and  more  permanent;  second,  the  lever  action  of  the  sound  or  repositor, 
by  which  the  operator  may  unwittingly  use  an  undue  and  dangerous 
amount  of  force,  is  avoided  in  the  use  of  the  hand;  third,  the  opera- 
tion is  not  only  constantly  under  the  operator's  control,  but  also  within 
his  appreciation.  Experience  has  abundantly  shown  that  instruviental 
uterine  reposition  by  means  of  the  sound  or  other  instruments  which 
enter  the  endometrium,  and  act  by  leverage,  is  unnecessary,  dangerous, 
and  therefore  usually  disapproved. 

Brandt  Method. — Manipulation  has  some  value  in  overcoming  the 
obstacles  to  replacement  and  has  well-defined  value  in  the  replacement 
of  a  uterus.  The  manipulations  described  below  are  those  of  Brandt. 
The  methods  of  Brandt  involve  much  complicated  massage  and  various 
gymnastic  movements,  and  are  available  only  to  the  specially  trained 
expert;  besides,  for  obvious  reasons,  when  long  continued  they  would 
be  regarded,  at  any  rate  in  this  country,  as  somewhat  objectionable 
even  though  entrusted  to  a  masseuse.  The  author  has  no  personal 
experience  in  the  administration  of  this  form  of  treatment,  nor  has  he 
been  able  usually  to  command  the  services  of  a  competent  and  satis- 
factory masseuse.  Certain  manipulations  of  the  Brandt  system, 
however,  apart  from  the  local  massage  and  the  associated  gymnastic 
movements,  are  adapted  to  the  detection  of  intrapelvic  lesions,  and 
therefore  are  set  forth  here  partly  for  their  diagnostic  value,  but  they 
are  presented  more  especially  for  their  value  in  the  replacement  of  the 
retroposed  uterus. 

Manipulation  in  the  Treatment  of  Retroposition  Complicated  by  Anterior 
Adhesions  and  Contractions. — A  serious  obstacle  to  replacement  and 
retention  of  a  retroposed  uterus  is  the  presence  of  contracted  tissue 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION     G57 


FiQuuE  374 


Stretching  adhesions  anterior  to  the  uterus. 
Figure  375 


Resisting  anterior  attachments.  Dorsal  position:  intravaginal  finger  pushes  cer^-ix  downward 
and  backward:  corpus  thrown  forward  on  its  transverse  axis;  right  hand  draws  corpus  upwara  ana 
forward  by  exerting  force  through  abdominal  wall. 

40 


658 


DISPLACEMENTS 


between  the  cervix  uteri  and  the  pubes,  which  antelocates  the  cervix 
to  such  an  extent  that  the  corpus  has  space  to  fall  back  under  the  sacral 
promontory.  Under  such  conditions  the  corpus  cannot  be  brought 
forward  and  retained  in  normal  anteversion  until  the  contracted  tissue 
or  bands  which  hold  the  cervix  forward  can  be  so  stretched  or  broken 
as  to  permit  the  cervix  to  return  to  its  normal  location  near  the  hollow 
of  the  sacrum;  this  may  sometimes  be  accomplished  by  manipulation, 
if  the  adhesions  and  contracting  bands  are  not  too  strong.  Several 
weeks  of  treatment  may  be  required  to  obtain  the  desired  result.  The 
manipulations  of  anterior  adhesions,  shown  in  Figures  374  and  375, 
are  as  follows: 

The  left  index-finger  is  introduced  first  back  of  the  cer^dx  and  the 
body  of  the  uterus  is  raised  as  far  as  practical  in  the  median  line.  The 
intravaginal  finger  is  then  transferred  to  the  front  of  the  cervix,  while 
the  external  hand  readily  pushes  the  uterus  backward,  so  as  to  move  it 
away  from  the  symphysis  and  still  further  stretch  or  break  the  adhesions. 
By  pressing  the  fingers  of  the  external  hand  down  behind  the  symphysis 
they  are  made  to  meet  the  intravaginal  fingers  in  front  of  the  uterus. 
The  fingers  of  the  two  hands  thus  brought  together  then  push  the  uterus 
in  the  following  directions:  the  internal  fingers  backward  and  upward, 
the  external  fingers  backward  and  downward.  This  manipulation 
should  not  be  carried  beyond  a  certain  limit  to  the  ready  extension 
of  the  tissues. 

FiGrRE  376  ■ 


Stretching  or  breaking  posterior  adhesions. 

Manipulation  in  the  Treatment  of  Retroposition  Complicated  by  Poste- 
rior Adhesions  and  Contractions. — Posterior  adhesions  and  contractions 


TREATMEXr  OF  RETROVERSION  AXD   RETROFLEXION     G59 

may  be  stretched  and  broken  on  the  same  principles  and  l)y  the  same 
manipiihitions  as  those  already  set  forth  for  anterior  adhesions  and 
contractions.     Figure  370. 

Replacement  and  Retention  of  the  Retroposed  Uterus 

When  the  uterus  is  mobile  and  not  too  sensitive,  replacement  and 
retention  in  the  normal  position  are  indicated,  and  may  be  accom- 
plished in  the  manner  set  forth  in  the  following  text  and  illustrations. 

Manual  Ventrovaginal  Reposition  of  the  Retroposed  Uterus 

Figures  377  to  381  taken  together  will  explain  an  efficient  method  of 
replacing  a  retroposed  uterus.  The  left  index-finger,  in  the  posterior 
vaginal  fornix  as  high  as  possible,  raises  the  uterus  toward  the  abdominal 
wall — Figures  377  and  378 — while  the  fingers  of  the  right  hand  above 

Figure  377 


Ventrovaginal  reposition;  beginning  of  first  step. 

the  symphysis  press  down  on  the  cervix,  the  point  of  pressure  being 
as  nearly  as  possible  the  plane  of  the  internal  os,  Figure  379.  The 
left  index-finger,  then  leaving  the  posterior,  passes  to  the  anterior 
fornix  and  approaches  the  fingers  of  the  right  hand.  Figure  380.  Both 
hands,  acting  together,  push  the  cervix  upward  and  backward,  while 
the  uterus  tends  to  fall  over  slightly  forward.  Then,  while  the  left 
index-finger  is  kept  fixed,  the  fingers  of  the  right  hand  are  passed  lightly 
along  the  right  border  of  the  uterus  until  they  pass  the  fundus,  which 
they  then  press  forward,  Figure  381.  The  organ  then  lies  extended 
along  the  left  index-finger.  It  is  essential  for  the  success  of  this 
manoeuvre  that  the  uterus  be  kept  in  the  median  line,  or  that  in  the 
replacement  it  be  swung  around  slightly  to  the  left.  Reposition  may 
be  facilitated  by  exerting  traction  on  the  uterus  by  means  of  a  vulsellum 
forceps  during  the  manipulation.     Figure  14. 


660 


DISPLACEMENTS 


Figure  378 


Ventrovaginal  reposition;  end  of  first  step. 


Figure  379 


Ventrovaginal  reposition;  second  step. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION     661 


Figure  380 


Ventrovaginal  reposition;  third  step. 


Figure  381 


Ventrovaginal  reposition;  final  step. 


662 


DISPLACEMENTS 

Figure  382 


Ventro-rectovaginal  reposition;  first  step. 
Figure  383 


^'entro-^ectovagiIlal  reposition;  second  step. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION     (;()3 


Manual  Ventro-rectovaginal  Reposition  of  the  Retroposed  Uterus. 

This  method  of  ri-i)lacement  is  illustrated  hy  Figures  382  to  384. 
The  left  index-finder,  lii<,di  up  in  the  reetuni,  puslies  the  fundus  for- 
ward, while  the  right  hand  on  the  ahdonien  executes  some  circular 
and  vibratory  movements.  As  the  muscles  relax,  the  external  fingers 
approach  the  fundus  and  push  it  downward,  so  that  it  may  readily  be 
reached  by  the  finger  in  the  rectum;  this  finger  is  aided  by  the  thumb 
in  the  vagina  pressing  the  cer\ix  backward.  The  fingers  of  the  right 
hand,  continuing  the  circular  movements,  then  insinuate  themselves  be- 
hind and  under  the  fundus,  and  complete  the  replacement.    Figure  384. 

Figure  384 


Ventro-rectovaginal  reposition;  final  step. 

The  degree  to  which  the  manipulations  are  necessary  will  depend 
upon  the  breadth  and  strength  of  the  adhesions  and  bands,  and  the 
amount  of  contraction  in  the  ligaments.  .4//  manipulations  should  be 
practised  only  on  cases  carefully  selected  according  to  the  indications 
and  contraindications  set  forth  in  the  beginning  of  this  chapter,  and  should 
be  as  gradual  and  as  free  from  pain  as  practicable} 

The  length  of  time  that  should  elapse  after  an  acute  inflammation 
before  manipulative  reposition  may  be  undertaken  with  safety  is  not 
less  than  two  months.     Pyosalpinx  is  always  a  contraindication.    The 

'  Figures  374  to  384  and  the  explanaton-  text  are  modified  from  Jentzer  and  Zeegenspeek. 


664 


DISPLACEMENTS 


nearer  the  time  to  an  acute  infection  the  more  virulent  the  pus  will 
be;  and,  on  the  contrary,  the  longer  the  time  the  more  likely  the  pus  is 
to  be  sterile.  If,  therefore,  on  account  of  error  in  diagnosis  the  manipu- 
lative movements  should  rupture  a  purulent  tube  and  force  the  con- 
tents of  it  into  the  abdomen,  the  danger  of  peritoneal  infection  would 
be  decreased  directly  with  the  length  of  time  that  had  elapsed  since 
the  acute  attack. 


Means   to  Retain  the  Replaced  Uterus 

The  uterus  having  been  replaced  will  seldom  retain  its  normal  posi- 
tion without  artificial  support.  This  support,  according  to  the  require- 
ments of  a  given  case  will  be  secured  by  means  of 

1.  Pessaries.  2.  Surgical  operations. 

Figure  385 


The  common  but  faulty  mode  of  introducing  a  pessary,  with  its  breadth  turned  in  the  anteroposterior 
diameter  of  the  vulva.  The  breadth  of  the  instrument  should  be  in  the  transverse  direction,  as  shown 
m  Figure  386. 


1.  Retention  by  Pessaries 
Contraindications  and  Indications  to  the  Pessary 

The  enthusiast  in  mechanical  gynecology  would  do  well  to  consider 
the  four  following  propositions: 


TREATMEST  OF   RETROV ERSIOS   AM)   RETROFLEXION      (if).') 

1.  Ill  the  majority  of  cases  of  retrodisplacement  the  essential  factor 
is  iiiflaiinnatioii.  and  the  resultant  tenderness  may  render  mechanical 
support  intolerable. 

2.  Adlu>sions  and  cicatricial  bands  may  pre\ent  or  prohibit  rejjlace- 
ment,  and  therefore  contraindicate  the  use  of  any  means  designed  to 
hold  the  organ  in  place. 

8.  A  tumor  or  excessive  weight  of  the  uterus  may  carry  the  corpus 
backward  and  downward  with  a  force  greater  than  any  pessary  can 
counteract. 

4.  The  peKic  floor,  inclutling  the  fascial  and  ligamentous  supports 
of  the  pelvic  organs,  may,  from  subinvolution  or  other  cause,  be  so 
relaxed  that  no  pessary  can  hold  the  organs  in  place. 

Figure  386 


A,  the  correct  mode  of  introducing  a  pessary.    B,  section  through  pelvis  shows:     U,  urethra;  V,  vagina; 
R,  rectum;  LV,  levator  ani  muscle. 


It  follows  from  the  above  that  the  field  for  the  use  of  the  pessary 
must  be  restricted  to  those  cases  in  which  the  displaced  organs  are 
replaceable,  and  in  which  the  pessary  is  capable  of  holding  them  in 
place,  and  can  be  worn  without  discomfort.  Failure  to  recognize  and 
appreciate  the  contraindication  accounts  not  only  for  the  failures 
and  disappointments,  but  also  for  the  many  evil  results  which 
have  followed  indiscriminate  attempts  to  treat  all  displacements  by 


666 


DISPLACEMENTS 


mechanical  support.  The  exclusion  of  unsuitable  cases  and  the  recog- 
nition of  the  necessity  for  accurate  diagnosis  are  apparent.  The  pessary, 
according  to  the  knowledge,  judgment,  and  mechanical  skill  of  the 
practitioner,  will  be  useful,  useless,  or  injurious. 

The  Function  of  the  Pessary 

The  function  of  the  pessary  is  to  maintain  the  uterus  not  only  on 
the  health  level  in  its  normal  location,  but  also,  if  possible,  in  its  normal 

Figure  387 


The  upper  end  of  an  Albert  Smith  pessary  being  pushed  into  place  back  of  the  cervix  uteri.  The 
apparent  lack  of  mobility  at  the  normal  angle  of  flexure  in  this  uterus  is  a  not  uncommon  result  of 
the  metritis  which  often  complicates  retroversion  and  retroflexion. 


position,  which  requires  the  cervix  to  be  about  one  inch  from  the  hollow 
of  the  sacrum.  The  cervix  in  a  properly  selected  case  being  thus  placed, 
retroversion  is  not  liable  to  occur,  because  if  it  does  occur  the  fundus 
uteri  will  be  arrested  in  its  backward  course  by  the  overarching  sacrum, 
and  because  the  direction  of  least  resistance  will  be  forward  into  the 
normal  anterior  position. 

It  follows  that  the  application  of  the  pessary  is  based  upon  the 
general  proposition  that  if  the  cervix  be  normally  placed  the  body  of 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION     ()G7 

tJw  ufcniff,  in  the  absence  of  com pJirai ions,  will  take  care  of  itself.  Since 
the  vagina  at  its  upper  extremity  is  attached  to  the  cervix,  displacement 
of  the  hitter  is  clearly  impossible  if  the  upper  extremity  of  the  vagina 
be  sustained  in  its  normal  location.  The  pessary  restores  and  main- 
tains the  relations  of  the  relaxed  vaginal  walls  by  crowding  the  posterior 
vaginal  cul-de-sac  backward  into  the  hollow  of  the  sacrum.  It  also 
holds  the  attached  cervix  at  a  proper  distance  from  the  sacrum,  and 
thereby  fulfils  its  indication  by  sustaining  the  pelvic  floor.  The  Hodge 
pessary,  or  some  modification  thereof,  answers  this  purpose  in  ordinary 
cases  more  satisfactorily  than  any  other. 

Figure  388 


Albert  Smith  pessary  in  place  and  uterus  maintained  in  normal  position. 


The  same  general  principles — in  fact,  the  same  pessaries — which 
are  applicable  to  prolapse  apply  also  to  retroversion  and  retroflexion, 
because  the  first  step  in  the  genesis  of  retro-malpositions  is  prolapse. 

Pessaries  designed  to  prop  up  the  body  of  the  uterus  by  pressure 
upon  the  posterior  wall  for  the  correction  of  posterior  malpositions,  and 
upon  the  anterior  wall  to  correct  anterior  malpositions,  are  not  only 
unnecessary,  but  they  are  also  very  liable  to  induce  metritis  and  peri- 
metritis, and  therefore  are  disapproved  generally.  In  certain  cases, 
however,  the  vaginal  walls,  especially  the  posterior,  may  be  so  relaxed 
from  subinvolution  and  other  causes  that  the  instrument,  though  very 
long,  fails  to  maintain  the  cervix  in  its  normal  place.     Under  such 


668 


DISPLACEMENTS 


conditions  an  instrument  may  be  required  to  act  directly  upon  the  uterus. 
The  Schultze  sleigh  pessary,  although  seldom  indicated,  represented 
in  Figure  391,  fulfils  this  indication.  A  long  Albert  Smith  pessary, 
with  its  uterine  curve  made  so  extreme  as  to  bring  the  upper  part  of 
the  instrument  in  front  of  the  cervix,  instead  of  behind,  may  answer 
the  same  purpose.  Experiments  of  this  kind,  however,  are  always  of 
doubtful  value. 

Adjustment  of  the  Pessary 

Figure  385  shows  a  common  but  faulty  manner  of  introducing  the 
pessary.  The  vagina  is  a  collapsed  tube,  the  anterior  walls  of  which 
rest  on  the  posterior;  hence,  the  long  diameter  of  a  cross-section  of 
the  canal  is  from  side  to  side,  not  anteroposterior.  The  pessary  should 
therefore,  be  introduced  with  its  lateral  edges  to  the  sides  of  the  vulva. 

If  introduced  as  shown  in  Figure  385  with  its  lateral  edges  in  the 
anteroposterior  direction  of  the  vulva,  the  pessary  is  apt  to  press 
painfully  against  the  urethra  in  front  and  the  perineum  behind.  This 
pain  is  increased  when  the  instrument  is  turned  to  conform  to  the 
shape  of  the  vagina,  as  it  must  be  before  it  can  take  its  proper  place. 

In  the  correct  mode  of  introduction  the  labia  are  separated  by  the 
thumb  and  index-finger  of  the  left  hand,  and  the  pessary  is  pushed 
in  with  the  right  hand,  its  lateral  edges  being  to  the  sides  of  the  vulva; 
it  then  readily  follows  the  curve  of  the  vaginal  outlet.  This  mode  of 
introduction  requires  less  force  and  gives  less  discomfort.  The  first 
step  toward  adjustment  is  complete  when  the  inner  end  of  the  pessary 
is  in  contact  with  the  anterior  wall  of  the  cervix  uteri.  The  second 
step  is  to  pass  the  left  index-finger,  the  palmar  surface  being  in  contact 
with  the  perineum,  under  the  pessary,  and  push  the  upper  end  under 
the  cervix  and  then  backward  into  its  place  in  the  posterior  vaginal 
fornix.     See  Figures  386,  387,  and  388. 


Figure  389 


Figure  390 


The  Emmet  curves. 


The  Albert  Smith  curves. 


The  curves  of  the  pessary  demand  careful  attention  in  its  applica- 
tion. When  the  uterus  is  below  the  normal  level,  the  broad  ligaments 
necessarily  are  rendered  more  tense  than  natural,  and  the  blood-vessels, 
more  especially  the  veins,  which  are  looped  one  upon  the  other,  and 
which  traverse  these  ligaments  to  and  from  the  uterus,  are  made  to 
collapse.  This  causes  venous  congestion  and  consequent  increase  in 
weight  of  the  uterus — a  condition  favorable  to  malposition,  uterine 


THE  ATM  EXT  OF  RETROVERSION  AND  RETROFLEXION     GG9 

catarrh,  and  patlu)l()<,ncal  chaiif^es  in  structure.  A  pessary  wliicli  will 
raise  the  uterus  to  the  health  level  clearly  fulfils  an  indication.  A 
pessary  which  raises  it  above  the  liealth  level  renders  the  broad  liga- 
ment tense  and  reproduces  a  condition  which  it  was  desipjned  to  re!ie\e. 
Maintenance  of  the  uterus  upon  the  health  level  depends  largely  ujion 
the  curves  of  the  pessary.  The  accompanying  cuts  illustrate  the  shape 
and  curve  of  the  Hodge  pessary  as  modified  by  Emmet  and  Albert 
Smith.  Figure  389  represents  the  curves  of  Emmet,  and  Figure  390 
those  of  Albert  Smith.  For  convenience,  let  us  characterize  that  curve 
which  rests  in  the  posterior  vaginal  cul-de-sac  as  the  uterine  curve, 

Figure  391 


Schultze's  sleigh  pessar\'  in  position.     This  pessary  is  not  in  general  use,  but  is  serviceable  to  hold  up 
the  vesicovaginal  wall  in  cases  of  cystocele  and  rectocele. 


and  that  which  occupies  the  part  of  the  vagina  adjacent  to  the  pubis 
the  pubic  cur^■e.  The  acuteness  and  length  of  the  uterine  curve  deter- 
mine the  height  to  which  the  pessary  will  lift  the  uterus.  The  longer 
and  more  acute  the  curve,  the  higher  the  uterus  will  be  lifted,  and 
vice  versa.  The  smaller  curve  of  the  Emmet  modification  will  answer 
the  average  indication  more  nearly  than  the  sharper  curve  of  the  Albert 
Smith  modification,  which  may  lift  the  uterus  too  high.  The  pubic 
should  generally  be  proportioned  to  the  uterine  curve — that  is,  the 
greater  the  uterine,  the  greater  the  pubic  curve.  A  pessary  properly 
adjusted  in  all  other  respects  may,  by  pressure  upon  the  urethra  and 


670 


DISPLACEMENTS 


neck  of  the  bladder,  create  vesical  tenesmus  and  urethral  irritation. 
This  calls  for  increase  in  the  pubic  curve — that  is,  the  pessary  should 
be  bent  away  from  the  irritated  part.  The  pubic  curve  may,  however, 
be  so  great  that  the  lower  part  of  the  pessary  occupies  the  centre  of 
the  vulva,  where  it  is  apt  to  create  irritation.  For  this  condition  les- 
sening of  the  pubic  curve  is  the  remedy.  The  pessary  should  not  be  so 
wide  as  to  distend  the  vagina.  The  length  should  be  measured  by  the 
distance  from  the  lower  extremity  of  the  symphysis  pubis  to  the  posterior 
vaginal  cul-de-sac,  less  the  thickness  of  the  finger.  If.  properly  adjusted 
in  a  suitable  case,  it  should  sustain  the  pelvic  floor  in  its  normal  relations 
and  the  uterus  in  stable  equilibrium. 

Thomas'  retroflexion  pessary,  with  its  bulbous  upper  extremity,  is 
a  long  narrow  instrument  of  extreme  uterine  curve.  It  lifts  the  uterus 
very  high,  and  is  especially  applicable  in  cases  of  great  relaxation  of  the 
pelvic  floor  and  of  complicating  prolapse  of  the  ovaries;  sometimes  the 
bulbous  portion  is  made  of  soft  rubber. 


Figure  392 


Thomas'  retroflexion  pessary. 


■  In  retroversion  and  retroflexion  always  replace  the  uterus  before 
adjusting  the  pessary,  otherwise  the  instrument  will  press  upon  the 
sensitive  uterus,  and  one  of  three  unfortunate  results  may  occur:  (a) 
the  pessary  may  not  be  tolerated  on  account  of  pain;  (6)  it  may  be 
forced  down  by  pressure  from  above  so  near  to  the  vulva  that  it  will 
fail  to  give  any  support;  (c)  the  uterus,  finding  it  impossible  to  hold 
its  position  against  the  pessary,  instead  of  taking  its  proper  position, 
may  be  bent  over  it  in  exaggerated  retroflexion,  with  the  cervix 
between  the  pessary  and  the  pubes,  or  the  whole  organ  may  slip  off 
to  one  side  of  the  instrument  into  a  malposition  more  serious  than 
the  one  for  which  relief  is  sought. 

A  properly  adjusted  pessary  gives  to  the  patient  no  consciousness 
of  its  presence.  If  the  instrument  causes  pain,  it  should  be  removed, 
and  search  made  for  the  tender  places ;  it  then,  if  possible,  should  be 
remoulded  into  such  shape  that  it  will  not  make  pressure  upon  them. 


TREATMENT  OF  RET  ROVE  RSI  Oy  A.VD   RETROFLEXION     071 

In  reinoiildinu-  a  hani-rubhcr  pessary,  one' should  pass  it  rapidly  hack 
and  forth  through  the  Hame  of  a  spirit  lamp  until  it  is  sufhciently 
softened  to  be  bent  to  the  desired  form.  Often  a  slight  indentation 
at  some  point  will  enable  the  patient  to  wear  it  with  comfort.  If  it 
cannot  be  made  comfortable,  it  should  be  abandoned. 

Sometimes  when  the  corpus  has  been  firmly  bound  back  by  peri- 
toneal adhesions  they  may  be  broken  up  by  very  forcible  conjoined 
manipulation  under  ether;  but  the  operation  is  dangerous,  and  should 
therefore  be  undertaken  only  by  an  expert  operator,  if  at  all. 

In  certain  cases  in  which  rei)lacement  is  impracticable  or  impos- 
sible, on  account  of  inflammation  or  adhesions,  a  soft  rubber  ring  may 
be  inserted,  and  will  sometimes  give  decided  relief  by  lifting  the  uterus 
and  pelvic  floor  nearer  to  the  health  level.  In  the  treatment  of  all 
displacements,  coition  should  be  forbidden  until  the  inflammatory 
signs  have  disappeared.  The  pessary  should  be  kept  clean  by  moderate 
daily  applications  of  the  vaginal  douche.  Every  three  or  four  wrecks 
the  instrument  should  be  removed  and  the  pelvic  organs  carefully 
examined. 

No  one  can  safely  apply  the  pessary  until  he  has  fully  appreciated 
its  indications  and  contraindications.  Many  practitioners  are  deficient 
in  the  natural  mechanical  skill  necessary  to  its  proper  adjustment — a 
fact  of  which  thousands  of  unfortunate  women  bear  witness.  Its 
dangers  in  inefficient  hands  are  in  striking  contrast  with  its  usefulness 
when  judiciously  employed  in  proper  cases. 

2.  Retention  by  Surgical  Operations 

Many  cases  of  displacement  are  so  complicated  by  prolapsed  and 
adherent  ovaries,  by  advanced  disease  of  the  ovaries  and  Fallopian 
tubes,  by  tumors,  by  inflammatory  exudates,  or  by  peritoneal  adhe- 
sions, that  non-surgical  replacement  is  impossible  or  dangerous,  or, 
replacement  being  possible  and  safe,  the  pessary  either  is  intolerable 
from  pain  or  proves  inadequate  to  sustain  the  uterus.  Such  cases 
furnish  definite  indication  for  surgical  treatment. 

Perineorrhaphy  elytrorrhaphy  and  the  removal  of  tumors  may  be 
necessary,  as  associated  operations,  and  have  been  considered  under 
their  respective  heads.  ^Yhenever  the  perineum  has  been  displaced 
downward  and  backward  away  from  the  pubes  toward  the  coccyx, 
its  restoration  by  perineorrhaphy  or  by  some  suitable  plastic  operation 
upon  the  vaginal  outlet  is  always  indicated.  Elytrorrhaphy  is  not 
usually  indicated  unless  the  retro-malposition  is  associated  with  descent 
to  the  second  or  third  degree.  If  the  malposition  is  caused  by  a  tumor, 
the  pathology,  diagnosis,  prognosis,  and  treatment  will  be  those  of  the 
tumor. 

The  surgical  treatment  proper  of  posterior  mal-positions  involves  espe- 
cially a  description  and  comparison  of  the  surgical  procedures  which 
are  most  recognized,  each  of  which  may  have  particular  adaptation 
to  its  own  class  of  cases.     These  operations  are: 


672  DISPLACEMENTS 

a.  Intra-abdominal  shortening  of  the  round  ligaments. 

b.  Shortening  of  the  uterosacral  ligaments. 

c.  Abdominal  hysterorrhaphy. 

d.  Vaginal  hysterorrhaphy  (hysteropexy). 


a.  Intra-abdominal  Shortening  of  the  Round  Ligaments 

The  round  ligaments,  as  already  explained,  restrain  the  uterus  from 
excessive  backward  movement.  They  are  two  cords,  each  the  size  of 
a  goose-quill,  springing  from  the  horns  of  the  uterus,  just  below  and 
in  front  of  the  origin  of  the  Fallopian  tube.  They  pass  forward  on 
either  side  in  the  folds  of  the  broad  ligaments  through  the  internal 
inguinal  rings,  through  the  inguinal  canals  and  the  external  rings,  and, 
spreading  out  in  strands,  are  lost  in  the  mons  veneris  and  upper  parts 
of  the  labia  majora.  These  ligaments  consist  of  unstriped  muscular 
fibres  in  condensed  areolar  tissue.  Physiologically  they  have  some 
contractile  power. 

When  the  uterus  is  retroposed,  the  round  ligaments  are  necessarily 
stretched  to  such  an  extent  that  they  can  no  longer  exert  their  normal 
restraining  power  upon  the  backward  movements  of  the  organ;  hence 
the  necessity  of  some  operation  to  shorten  them  to  such  an  extent  that 
they  will  resume  their  normal  functions. 

Alexander's  operation  and  other  operations  for  shortening  the  round 
ligaments,  whether  by  means  of  incision  into  each  inguinal  canal  or 
through  the  inguinal  region  on  either  side  into  the  pelvic  cavity,  have 
in  great  measure  and  for  good  reason  given  way  in  later  years  to  more 
practical  procedures  in  which  the  ligaments  are  treated  intraperito- 
neally  through  a  median  laparotomy  incision. 

The  Gilliam  Type  of  Operation. — In  the  excellent  operation  of 
Gilliam  and  the  improvements  on  it  recently  introduced  by  Barrett 
and  others  the  round  ligaments  are  drawn  through  an  artificial  canal 
into  the  laparotomy  wound  and  fastened  there  either  to  one  another 
or  to  the  corresponding  sides  of  the  wound,  so  that  this  wound  when 
closed  shall  contain  the  loops  of  the  ligaments  thus  drawn  into  it. 

The  method  is  satisfactory  provided  there  is  no  subsequent  suppura- 
tion in  the  abdominal  wound,  but  it  should  be  a  fair  a  priori  conclu- 
sion that  if  the  wound  becomes  infected  the  infection  would  be  apt  to 
extend  through  the  tracks  of  the  ligaments  into  the  peritoneal  cavity, 
and,  to  say  nothing  of  unnecessary  spreading  of  infection,  might  at  least 
defeat  the  purpose  of  the  operation.  The  danger  of  such  a  source  of 
infection  is  obviated  by  the  modified  technique  about  to  be  described. 
This  technique  has  for  its  object  the  making  of  an  artificial  inguinal 
canal  on  each  side,  through  which  a  loop  of  the  round  ligament  is  drawn 
and  anchored,  not  in  the  abdominal  wound,  but  on  the  peritoneal 
surface  at  a  point  a  little  distant  from  and  independent  of  the  wound. 
It  will  be  observed  that  the  uterus  which  appears  retroverted  in 
Figure  393  takes  its  anteverted  position  in  Figure  394. 


TREATMEXT  OF  RETROV EliSlOX   AXD  RErROFLEXION     67.'^ 

Postuterine  Shortening  of  the  Round  Ligaments. — A  \ery  satisfactory 
operatioii  of  sliortciiiiig  the  round  ligaments  for  retrodisplacements 
of  the  uterus  is  that  described  by  J.  Clarence  Webster  and  J.  Mont- 
gomery Baldy.     It  consists  in  attaehin<i-  strong  thread  to  each  relaxed 

FltilHE    M'.i 


Shortening  Round  Ligaments. — The  abdomen  is  opened  in  the  median  line  just  above  the  pubes 
and  the  wound  is  held  apart  widely  by  retractors  so  as  to  expose  the  pehac  contents.  The  middle  of 
the  relaxed  round  hgament  is  seized  vnth  forceps  and  tied  mth  a  catgut  suture  at  a  point  just  above  A. 
The  two  free  ends  of  this  suture  are  then  threaded  on  a  cursed  blunt-pointed  needle  the  size  of  a  goose- 
quill  and  this  needle  is  then  thrust  through  peritoneum  at  the  internal  abdominal  ring,  traction  on  the 
Ugament  having  been  made  in  order  to  locate  the  ring  at  point  A.  The  needle  is  then  passed  on  through 
the  rectus  muscle  and  fascia  and  then  turned  and  forced  through  fascia,  muscle,  and  peritoneum  to  its 
point  of  exit  close  to  the  bladder  reflexion,  about  one  and  one-half  inch  from  the  peritoneal  margin 
of  the  abdominal  incision  at  point  B.  The  blunt  needle  is  then  removed  and  the  loop  of  ligament 
is  drawn  through  the  artificial  inguinal  canal  by  means  of  the  suture  from  A  to  B,  as  shown  on  the 
right  side  of  Figure  .394.  In  place  of  this  blunt  needle  one  may  use  a  Ugature-carrj-ing  forceps.  The 
artificial  canal  lies  between  points  .-1  and  B.  In  order  to  avoid  wounding  the  deep  epigastric  and  other 
ves.sels  the  needle  should  be  blunt-pointed  and  the  plunge  of  it  should  not  be  too  deep  into  the  region 
of  the  internal  ring.  The  needle  should  be  about  two  and  one-half  inches  long  and  flattened  both  on 
its  convex  and  concave  sides  in  order  that  it  may  be  held  firmly  in  the  needle  forceps,  and  with  a 
point  especially  blunt  to  make  it  pass  by  blood-vessels  without  wounding  them,  but  not  so  blunt  as 
to  prevent  introduction. 

round  Hgament  near  its  middle  part  perforating  the  broad  ligament 
at  the  uterine  junction  just  below  the  ovarian  ligament  with  forceps, 
seizing  the  thread  with  the  forceps  and  drawing  the  loop  of  the  ligament 
through  the  punctured  broad  ligament,  and  uniting  the  loops  of  the  two 
41 


674 


DISPLACEMENTS 


ligaments  posterior  to  the  uterus,  and  then  fastening  the  united  loops 
to  the  posterior  wall  of  the  corpus  near  the  fundus  uteri.  The  steps 
of  the  procedure  are  shown  in  Figures  395,  396,  and  397.  The  loops  of 
the  ligaments  ha\'ing  been  fastened  posterior  to  the  uterus,  it  is  well 
to  insure  a  permanent  result  by  fastening  each  round  ligament  to  the 
anterior  wall  of  the  uterus  at  a  point  near  the  opening  through  which 

FiGUEE  394 


Continuation  of  Figure  393.  The  ligament  ha-s-ing  been  drawn  through  the  artificial  inguinal  canal 
is  then  stitched  with  catgut  at  its  point  of  entrance  at  .i,  and  the  loop  in  a  similar  manner  is  stitched 
down  on  the  peritoneum  at  the  point  of  exit  B.  The  left  side  of  the  figure  shows  the  ligament  thus 
stitched  at  the  point  of  entrance  and  being  stitched  at  its  point  of  exit.  This  ha'i'ing  been  done  on  both 
sides  the  shortening  is  completed.     The  abdominal  wound  is  then  closed. 


it  penetrates  the  broad  ligament.  A  rather  slender,  blunt-pointed 
forceps  should  be  used  in  perforating  the  broad  ligament,  and  the 
perforations  should  be  made  close  to  the  uterus,  almost  invoh-ing  the 
utenne  muscularis,  otherwise  there  may  be  troublesome  hemorrhage 
from  wounding  of  the  utero-ovarian  anastomosis.  One  or  two  linen 
sutures  should  be  used  in  fastening  the  round  ligament  to  the  posterior 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION      675 

wall  of  the  uterus.     The  remaining  sutures  should  be  Xo.  1  chromic 
catgut. 

Figure  395 


The  slack  portion  of  the  round  ligament  is  here  caught  up  with  a  thread  preparatorj-  to  drawing  it 
through  the  perforated  broad  ligament  to  the  posterior  wall  of  the  uterus.  The  same  procedure  is 
to  be  repeated  on  the  opposite  side. 

Figure  396 


The  round  Ugament  loops  are  being  stitched  posterior  to  the  corpus  uteri.  If  there  is  great  slack- 
ness of  the  ligaments  they  should  be  stitched  in  contact  with  one  another.  Otherwise  they  should 
be  stitched  to  such  points  on  the  posterior  surface  of  the  corpus  as  to  secure  normal  anteversion.  If 
the  ligaments  are  drawn  so  tightly  as  to  create  great  tension,  they  are  apt  to  necrose  with  resultant 
failure  of  the  operation. 


Crumpling  the  Round  Ligaments  upon  Themselves. — In  some  cases 
the  ligament  on  one  or  both  sides  vn\\  be  found  to  be  absent  or  so 
attenuated  as  to  give  little  hope,  even  though  shortened,  of  being 
adequate  to  sustain  a  heavy  uterus.    It  may  then  be  well  to  substitute 


676 


DISPLACEMENTS 


for  the  above  operation  the  procedure  shown  in  Figure  398,  which  is  to 
crumple  the  rudimentary  hgament  upon  itself  by  means  of  a  purse- 
string  catgut  suture  running  from  the  internal  inguinal  ring  to  the  uterus. 


FiGUEE  397 


Operation  complete,  showing  suture  of  the  round  ligaments  both  posterior  and  anterior  to  the  uterus. 

Figure  398 


Crumpling  Round  Ligaments  on  Themselves. — Traction  made  on  the  ligament  will  locate  its 
point  of  entrance  at  the  internal  inguinal  ring.  An  ordinarj-  needle  is  introduced  at  this  point  and 
the  round  hgament  and  the  adjacent  part  of  the  broad  ligament  are  caught  up  from  point  to  point 
lantil  the  suture  finally  is  brought  out  in  uterine  tis.sue  near  the  uterine  end  of  the  round  hgament. 
The  tjdng  of  the  suture,  which  should  not  be  drawn  too  tightly,  shortens  and  strengthens  the  ligament 
by  crumpling  it  on  itself.  If  the  ligament  is  absent  or  highly  attenuated,  the  structures  of  the  broad 
ligament  between  the  horn  of  the  uterus  and  the  internal  ring  may  be  brought  together  by  a  .similar 
suture  with  similar  result.  Before  tying  the  sutures  the  surfaces  to  be  united  should  be  scarified  in 
order  to  secure  strong  union. 


TREATMENT  OF  RETROVERSIOX   AM)   RETROFLEXION     677 


b.  Shortening  the  Uterosacral  Ligaments 

Any  operation  for  shortenino^  or  strengthening  the  round  Hgaments 
may  fail  to  gi\e  satisfactory  resuhs  if  the  uterosacral  ligaments  are  so 

Figure  399 


The  uterosacral  ligaments  are  exposed  and  a  purse-strins  suture  is  introduced  for  the  purpose  of 
shortening  them  and  partially  tied,  but  not  drawn  taut.  Before  tightening  the  sutures  the  surfaces 
to  be  united  should  be  scarified  in  order  to  insure  firm  union  of  the  peritoneal  surfaces.  In  order  to 
avoid  wounding  important  nerves  and  vessels  the  sutures  should  be  passed  superficially. 


FlGITRE   400 


Continuation  of  Figure  399.  The  catgut  sutures  shown  in  Figure  39S  are  now  drawn  taut  and 
tied.  These  sutures  ha'ving  been  tied  usually  should  be  fortified  by  an  additional  suture  through 
the  crumpled  ligament  on  each  side.  This  figure  shows  the  cerzix  uteri  drawn  well  back  into  its  normal 
location  so  near  the  hollow  of  the  sacrum  that  the  corpus  cannot  have  room  to  fall  back  into  its  former  retro- 
verted  position. 


678 


DISPLACEMENTS 


relaxed  that  they  cannot  perform  their  function  of  holding  the  cervix 
uteri  in  its  normal  location  back  in  the  hollow  of  the  sacrum.  It  may 
be  necessary,  therefore,  that  these  ligaments  be  shortened  also.  Figure 
399  and  400  illustrate  the  operation  usually  performed  for  this  purpose, 
and  show  the  change  which  the  shortening  makes  in  the  location  of  the 
cervix  uteri.  Reference  here  is  made  to  shortening  the  ligaments 
only  through  an  abdominal  incision.  A  very  exhaustive  paper  on 
shortening,  both  vaginal  and  abdominal,  of  the  uterosacral  ligaments, 
with  bibliography,  by  J.  Wesley  Bovee,  may  be  found  in  the  Trans- 
actions of  the  American  Gynecological  Society,  1902. 


Figure  401 


Suture  wrongly  placed  in  the  anterior  wall  of  the  corpus  uteri.  The  arrow  points  in  the  direction 
of  the  forces  that  fall  on  the  anterior  uterine  wall  and  tend  to  force  the  organ  back,  and  thereby  to 
reproduce  the  displacement. 


C. 


Abdominal  Hysterorrhaphy 


Hysterorrhaphy  has  been  known  under  various  names,  some  of  them 
more  or  less  descriptive  of  special  methods  of  operation.  They  are: 
ventral  fixation,  abdominal  fixation,  suspensio  uteri,  and  hysteropexy. 

The  Conditions  of  Successful  Hysterorrhaphy  require  that  the  sutures 
should  be  placed  slightly  posterior  to  a  line  connecting  the  two  horns 
of  the  uterus — ^that  is;  in  the  posterior  wall.  The  earlier  operators 
stitched  the  anterior  w^all  of  the  corpus  to  the  abdominal  wall.  By  this 
arrangement  the  uterus  is  so  placed  that  contraction  of  the  abdominal 
muscles  and  the  intra-abdominal  forces  must  be  exerted  against  the 


TREAT M EXT  OF  RETROVERSION  AXD  RETROFLEXION     079 

front  of  the  uterus,  and  must  therefore,  in'  forcing;  tlie  uterus  haek, 
ultimately  streteh  or  break  the  adhesions  and  reproduee  the  disjjlace- 
ment.  If,  on  the  contrary,  the  posterior  wall  of  the  corpus  be  stitched 
properly  to  the  anterior  abdominal  wall,  all  the  forces  from  above 
are  exerted  on  the  posterior  wall  of  the  corpus,  and  thereby  tend  to 
perpetuate  the  normal  anterior  position. ^ 

Another  condition  of  success  is  to  limit  the  adhesions  between  the 
uterus  and  the  abdominal  wall.  When  the  adhesion  is  to  the  posterior 
wall  of  the  corpus  uteri,  it  is  surprisiufj  how  slight  it  may  be  and  yet 
make  a  permanently  good  result.     The  object  of  the  operation  is  not 

Figure  402 


Posterior  wall  of  the  corpus  properly  stitched  to  the  anterior  abdominal  wall.  The  arrow  shows 
the  direction  of  forces  from  above  so  exerted  as  to  fall  on  the  posterior  uterine  wall,  and  thereby 
perpetuate  the  normal  anterior  position. 


to  fix  the  uterus  immovably  to  the  abdominal  wall  by  broad  areas  of 
adhesion;  such  a  result  is  produced  sometimes  by  numerous  deep 
sutures  and  extensive  scarifications  of  the  anterior  or  posterior  face 
of  the  uterus.  The  broad  unyielding  adhesions  thus  obtained  must 
interfere  with  the  normal  movements  of  the  uterus,  and  thereby  give 
rise  to  a  condition  more  distressing  than  the  displacement.  Figure 
403  shows  the  abdomen  open  and  three  hysterorrhaphy  sutures  passed, 
but  not  tied. 

Occasional  cases  of  dystocia,  some  of  them  demanding  craniotomy 
or  Caesarean  section,  bear  witness  to  the  danger  of  excessive  uterine 

•  The  necessity  for  uniting  the  posterior  wall  of  the  corpus  uteri,  instead  of  the  anterior  wall,  to 
the  parietal  peritoneum  of  the  abdominal  wall,  was  pointed  out  first  by  Howard  Kelly. 


680  DISPLACEMENTS 

adhesions  to  the  abdominal  wall.  After  the  operation  the  adhesions, 
if  properly  made,  do  not  remain  as  such,  but  stretch  out  so  far  as  to 
form  a  short,  ribbon-like  band  between  the  uterus  and  the  abdominal 
wall.  This  band  contains  connective  tissue  and  possibly  some  fibres  from 
the  recti  and  uterine  muscles,  and  is  covered  by  peritoneum;  it  is  there- 
fore a  new  suspensory  ligament  designed  to  supplement  the  inadequate 
uterine  ligaments.  This  ligament  has  been  demonstrated  by  dissection 
years  after  the  operation. '^  It  is  usually,  when  fully  stretched,  about 
two  inches  long.  This  elongation  of  the  adherent  structures  into  a 
new  uterine  ligament  cannot  occur  if  the  adhesions  are  too  extensive 
and  too  strong. 

Technique  of  Hysterojrhaphy. — The  incision,  general  conduct  of  the 
operation,  closure  of  the  wound,  and  after-treatment  are  the  same  as 
for  any  other  abdominal  section.     See  Chapters  VL,  VII.,  and  VIII. 

The  introduction  of  the  hysterorrhaphy  sutures  varies  in  minor 
details  according  to  the  individual  preference  of  the  operator.  The 
writer  uses  two  formaldehyde  catgut  sutures,  one  on  each  side  of  the 
posterior  wall  of  the  corpus  uteri. 

An  abdominal  incision  from  one  to  two  inches  long  is  made  in  the 
median  line  just  above  the  pubes.  The  margins  of  the  peritoneum 
are  drawn  through  the  wound  over  the  cutaneous  margins,  and  are 
held  outside  by  haemostatic  forceps,  as  shown  in  Figure  394.  The 
corpus  uteri  is  lifted  forward  by  the  left  index-finger  and  middle  finger 
introduced  through  the  wound,  and  is  held  in  place  by  light  vulsellum 
forceps  in  the  hands  of  an  assistant. 

The  teeth  of  the  forceps  grasp  the  posterior  surface  of  the  corpus  in 
the  median  line  about  one-half  inch  back  of  the  summit  of  the  fundus. 
The  operator,  standing  on  the  patient's  right,  passes  a  short  needle 
slightly  curved  at  the  point  and  threaded  with  fine  formaldehyde  cat- 
gut, into  the  everted  peritoneum  on  the  left  side.  The  needle  enters 
just  above  the  lower  angle  of  the  wound,  about  three-quarters  of  an 
inch  from  the  peritoneal  margin;  it  dips  down  about  one-quarter  of  an 
inch  so  as  to  include  some  fibres  of  the  rectus  muscle,  and  emerges 
about  one-half  inch  from  the  point  of  entrance.  The  needle  then  is 
reintroduced  into  the  posterior  wall  of  the  corpus  to  one  side  of  the 
median  line  near  the  horn  of  the  uterus.  *Care  should  be  taken  not  to 
puncture  the  Fallopian  tube.  The  uterine  part  of  the  suture  should 
include  sufficient  peritoneal  and  subperitoneal  tissue  to  give  it  a  strong 
hold  on  the  uterus.  The  free  ends  of  this  suture  now  are  fastened 
together  by  snap-forceps  and  laid  to  one  side.  Another  similar  suture 
is  passed  on  the  opposite  side.  It  is  convenient  in  passing  this  to  do 
so  in  the  reverse  order — that  is,  to  pick  up  the  uterus  first  and  the 
abdominal  peritoneum  second.  A  third  suture  now  is  introduced 
through  the  parietal  peritoneum  near  the  first  suture,  then  through 
the  corpus  uteri  between  the  two  first  sutures  and  through  the  parietal 
peritoneum  near  the  second.    The  three  sutures  being  thus  passed,  a 

1  Penrose.     Diseases  of  Women. 


TREAT M EXT  OF   RETROVERSIOX   A\D   RETROFLEXION      081 

final  oxainination  of  the  pehic  conteHts  is  madr;  and  if  all  is  well,  the 
sutures  are  tied.  This  secures  the  uji]ier  posterior  wall  of  the  corpus 
uteri  to  the  anterior  abdominal  wall.  The  external  wound  then  is 
closed  by  continuous  catgut  suture,  as  directed  in  Chapter  VI.  There 
is  no  occasion  for  scarifyiny,-  the  peritoneal  surfaces;  indeed,  this  should 
not  be  done.  Adequate  adhesion  will  always  form  from  the  presence 
of  the  sutures.     The  pessary  is  not  needed  during  convalescence. 

Figure   103 


Peritoneal  margins  of  the  wound  extremely  everted  by  hfemostatic  forceps.  Corpus  uteri  held  steady 
by  a  ^^^lsellum  forceps.  Sutures  on  both  sides  and  in  the  centre  of  the  corpus  passed  but  not  tied. 
This  extreme  degree  of  eversion  of  the  peritoneum  ordinarily  would  not  be  possible;  it  is  so  shown 
here  for  purposes  of  illustration. 


Immediately  after  the  operation,  while  the  uterus  is  fixed  immov- 
ably, there  may  be  some  bladder  irritation;  but  in  a  few  weeks,  when 
the  adherent  structures  have  stretched  and  formed  a  new  suspen- 
sory ligament  and  the  uterus  has  assumed  its  normal  state  of  mobile 


682  DISPLACEMENTS 

equilibrium,  the  Vesical  irritation  disappears.  This  operation  properly 
performed  gives  great  security  against  recurrence  of  displacement.  Certain 
contraindications  will  be  given  later. 

d.  Vaginal  Hysterorrhaphy  ^ 

The  purpose  of  this  operation  is  to  anchor  the  uterus  in  its  normal 
anterior  position  by  stitching  the  anterior  wall  of  the  uterus  to  the 
anterior  wall  of  the  vagina. 

Technique  of  Vaginal  Hysterorrhaphy . — Vaginal  section  is  made  as 
directed  in  Chapter  XX.  The  patient  is  on  her  back,  with  the  cervix 
uteri  and  anterior  vaginal  wall  exposed  by  means  of  Simon's  speculum 
and  other  retractors.  The  uterus  is  draw^n  downward  and  backward  by 
means  of  vulsellum  or  bullet  forceps.  The  anterior  vaginal  wall  is  put 
upon  the  stretch  by  means  of  a  small  vulsellum  forceps  fastened  to  the 
vagina  in  the  median  line  midway  between  the  meatus  urinarius  and 
the  cervix  uteri.  A  median  longitudinal  incision  then  is  made  in  the 
anterior  vaginal  wall  extending  from  the  cervix  uteri  one  inch  or  more 
toward  the  meatus.  This  incision,  which  divides  the  vaginal  wall, 
but  does  not  invade  the  bladder-wall,  is  separated  by  retractors,  the 
cervix  is  drawn  more  strongly  forward,  and  the  loose  cellular  tissue 
adjacent  to  the  anterior  wall  of  the  cervix  is  stripped  back  by  means  of 
the  finger  or  blunt  instrument  until  the  uterovesical  reflection  of  the 
peritoneum  is  reached.      Figure  175. 

A  sound  in  the  bladder  will  distinguish  the  peritoneum  from  the 
bladder-wall.  The  peritoneum,  then  exposed,  is  seized  with  the  tenac- 
ulum or  snap-forceps,  and  divided  with  blunt  scissors.  The  peritoneal 
opening  next  is  enlarged  by  introducing  the  two  index-fingers  and 
tearing  and  stretching  it  laterally,  or  by  careful  cutting  with  the  scissors. 
The  large  opening  thus  made  between  the  uterus  and  the  bladder  will 
permit  the  bladder  to  be  pushed  up  out  of  the  way  and  the  corpus  uteri 
to  be  drawn  through  into  the  vagina  and  down  to  the  vulva.  If  there 
are  restraining  posterior  or  lateral  adhesions,  they  may  be  broken 
up  by  the  finger  introduced  through  this  opening  or  through  a  similar 
one  made  for  the  purpose  posterior  to  the  uterus.  See  Posterior  Vaginal 
Section.  The  uterus,  being  freed,  is  drawn  into  the  vagina  by  succes- 
sively grasping  its  anterior  wall  with  two  pairs  of  vulsellum  forceps, 
one  in  each  hand,  using  first  one  and  then  the  other,  until  the  fundus 
finally  appears  and  with  it  the  appendages.  Any  necessary  operation 
on  the  uterus  or  its  appendages  may  now  be  performed;  there  may  be 
a  small  myoma  to  be  enucleated,  or  some  conservative  or  radical  opera- 
tion to  be  performed  on  the  uterine  appendages.  The  uterus  is  now 
ready  to  be  fastened  to  an  anterior  vaginal  wall,  as  follows: 

A  needle,  such  as  would  be  used  for  closing  the  lacerated  cervix,  is 
threaded  with  silkworm-gut,  and  by  means  of  the  needle-forceps  is 

1  This  operation  has  passed  through  numerous  modifications,  is  still  sub  judice,  and  is  not  strongly 
recommended.  Among  the  names  chiefly  associated  with  the  evolution' are  those  of  Schiicking,  Sanger, 
Mackenrodt,  Dtihrssen,  Byford,  and  Vineberg. 


TREATMENT  OF  RETROV ERSIOX   AM)   RETROFLEXION     083 

passed  through  the  llap  of  the  \a^iiuil  incision  near  tlie  urethra,  on  the 
patient's  left,  then  continued  trans\ersely  thr()Uji;h  the  anterior  wall 
of  the  uterus  near  the  fundus,  and  brought  out  through  the  vaginal 
flaj)  on  the  opposite  side.  Another  similar  suture  is  j^assed  immediately 
below  this.  These  uterine  sutures  are  not  tied  until  after  closure  of  the 
vaginal  incision.  The  vaginal  incision  is  closed  with  a  continuous 
buried  catgut  suture  in  a  manner  similar  to  that  described  in  Chapter 
VL,  for  closure  of  an  abdominal  wound.  The  vagina  is  packed  lightly 
with  aseptic  gauze  and  an  aseptic  dressing  is  i)laced  over  the  vulva. 
The  dressings  should  be  changed  often  enough  to  keep  them  clean. 
After  three  days  the  vaginal  gauze  may  be  left  out,  and  in  its  place  may 
be  given  a  daily  hot  aseptic  vaginal  douche.  The  silkworm-gut  sutures 
are  removed  in  four  weeks.  Chromic  catgut,  if  used  in  place  of  silk- 
worm, need  not  be  removed.^ 

Unless  the  adhesions  between  the  uterus  and  the  vagina  be  very 
broad  and  very  strong,  they  are  liable  in  a  few  w^eeks  to  give  way, 
with  complete  return  of  the  displacement.  If,  on  the  other  hand,  the 
adhesions  are  sufficiently  strong  and  broad  to  make  a  permanent  ana- 
tomical cure,  and  pregnancy  follows,  the  danger  from  dystocia  is  very 
great.  Numerous  cases  have  been  reported,  some  of  them  fatal,  in 
which  Caesarean  section  or  other  grave  obstetrical  operations  became 
necessary  for  delivery.  The  operation  therefore,  as  described  above, 
is  not  approved  for  eases  in  which  pregnancy  may  occur. 

Complicating  Versions  and  Flexions 

The  lateral  malpositions  which  often  complicate  retroversion  and 
retroflexion  are  usually  the  result  of  inflammation  in  a  broad  ligament, 
or  in  the  uterus,  or  in  both.  They  are  caused  sometimes  by  a  tumor 
of  the  uterus  or  its  appendages.  The  treatment  is  that  of  the  causa- 
tive inflammation  or  tumor,  and  follow^s  the  general  principles  that 
have  been  laid  down  for  the  treatment  of  these  conditions.  Pessaries 
are  of  little  or  no  use. 

In  Congenital  Retroversion  and  Retroflexion  it  is  doubtful  whether  any 
treatment,  surgical  or  non-surgical,  is  of  the  least  value.  This  form 
of  displacement  is  associated  usually  with  faulty  development  both 
general  and  local.  The  concurrent  symptoms  also  are  due  rather 
to  general  than  to  local  causes. 

As  a  partial  summing  up  of  the  relative  value  of  various  operations  which  has 
been  established  as  reliable  in  the  surgical  treatment  of  retrodeviations  of  the  uterus, 
I  introduce  here  my  remarks  on  that  subject,  which  were  made  in  the  Section  of 
Obstetrics  and  Diseases  of  Women  of  the  American  Medical  Association  at  the 
Sixty-first  Arinual  Session  held  at  St.  Louis,  June,  1910. 

"I  desire  at  the  outset  to  enter  a  disclaimer,  in  that  I  believe  that  the  surgical 
treatment  of  deviations  of  the  uterus  and  associated  pelvic  organs  is  far  from 
settled,  so  far  that  perhaps  some  of  the  hysteropexies,  the  ligament  shortenings, 

'  The  method  described  above  is  similar  to  that  advocated  and  successfully  practised  by  Vineberg. 
New  York  Medical  Journal,  October,  1894. 


684  DISPLACEMENTS 

the  suspensions,  the  fixations,  in  their  wide  divergence  may  to  the  next  genera- 
tion look  as  crude  and  unscientific  as  the  routine  clamp  and  drainage-tube  in 
ovariotomy  now  look  to  us.  Perhaps  we  are  somewhat  inclined  prematurely 
to  dogmatize  on  the  subject — and  especially  the  inventor  of  an  operation  is 
like  the  expert  witness,  who  said:  'Your  honor,  in  matters  of  fact  I  am  often 
mistaken,  but  in  matters  of  opinion  I  know  I  am  right. ' 

"The  fine  adjustment  of  the  mere  mechanical  technique  of  any  or  all  of  the 
current  operations  is  of  less  consequence  than  the  selection  of  suitable  cases 
and  the  recognition  of  the  facts  that  surgical  measures  are  not  demanded  for 
all  retrodeviations;  that  there  is  no  fixed  normal  position  of  the  pelvic  organs; 
that  the  matter  is  one  rather  of  normal  movements  than  of  normal  position; 
that  the  normal  supports,  so-called,  are  functionally  concerned,  not  with  hold- 
ing the  organ  in  some  fixed  position,  but  rather  with  restraining  it  within  its 
normal  range  of  movements;  that  a  uterus  out  of  place,  if  you  please,  may 
by  a  surgical  procedure  be  put  in  place  and  so  fixed  that  the  fixation  is  more 
injurious,  more  embarrassing  than  the  displacement. 

"Many  would  say,  not  without  reason,  that  we  all  are  prone  to  treat  this 
subject  from  purely  mechanical  points  of  view  and  thus  to  lose  sight  of  essential 
pathological  changes  which  have  produced  mechanical  deviations,  treating 
effect  instead  of  cause,  like  damming  up  a  river  to  prevent  its  waters  from 
flowing  into  the  ocean.  But  on  the  other  hand  we  must  not  forget  that  if  the 
resources  of  Nature  have  been  exhausted  in  the  production  of  the  lesion  we  may 
have  recourse  sometimes  to  mechanical  measures,  irrespective  of  the  fact  that 
if  an  ideal  anatomical  and  physiological  cure  is  impossible  yet  a  symptomatic 
cure  may  be  desirable. 

"Confining  the  discussion  to  the  relative  merits  of  those  procedures  which 
now  have  the  support  of  progressive  surgery  we  may  classify  them  under  two 
heads : 

"1.  Operations  which  give  sustaining  power  by  means  of  peritoneal  adhesions 
or  fixation. 

"2.  Operations  which  give  sustaining  power  by  shortening  of  ligaments. 

"In  the  interest  of  brevity  we  may  disregard  surgical  operations  of  whatever 
class  which  are  performed  by  vaginal  section,  not  that  we  should  condemn 
vaginal  hysteropexy  in  Mo,  but  that  the  field  is  relatively  narrow,  and  the 
discussion  is,  therefore,  in  this  place  to  some  degree  unprofitable. 

"The  different  procedures,  therefore,  so  far  as  I  shall  weigh  them,  narrow 
down  to  operations  performed  through  the  median  or  nearly  median  abdominal 
section. 

"Touching  the  class  of  operations  which  give  sustaining  power  by  sero- 
serous  adhesion  or  fixation,  that  is,  ventral  suspensions  and  ventral  fixations, 
some  will  remember  thirty  years  ago  when  it  was  a  vexed  question  what  to 
do  with  a  retroverted  uterus  before  closing  the  abdomen  after  a  pelvic  opera- 
tion, such  for  example,  as  the  removal  of  pus-tubes.  Sometimes  cautiously  and 
tentatively,  and  with  some  misgivings,  having  a  pioneer  respect  for  the  peri- 
toneum, we  united  with  a  single  stitch  the  fundus  or  the  anterior  wall  of  the 
corpus  uteri  to  some  point  in  the  peritoneum  near  the  pubes.  In  a  few  weeks 
examination  usually  disclosed  the  uterus  again  retroverted  and  thereby  demon- 
strated the  inadequacy  of  this  technique ;  then  several  sutures  were  used  instead 
of  one  with  the  same  result;  then  before  suturing  we  scraped  off  with  a  sharp 
knife  the  peritoneal  surface  so  as  to  give  raw  surfaces  to  be  united  and  the 
result  was  strong  broad  cicatricial  union  and  permanent  fixation;  in  fact, 
immobilization  of  the  uterus;  then  was  written  the  tragic  and  humihating 
chapter  of  mechanical  fixation  of  the  uterus,  a  chapter  which  told  of  obstruction 
of  the  bowel,  dystocia,  rupture  of  the  parturient  uterus  and  other  obstetrical 
calamities,  not  to  mention  a  formidable  list  of  disabling,  distressing  consequences, 
neurotic  and  circulatory,  local  and  general.  Ventral  fixation  then  relegated 
to  the  dark  ages  of  surgery  soon  gave  way  to  ventral  suspension  of  the  uterus 
by  less  barbarous  methods — an  operation  popularized  by  Howard  KeUy,  which 


TREATMEST  OF   RETROVERSrON   A  X  I)    RErROFLEXJON     ()85 

in  the  final  and  successful  evolution  resulted  ((uitt!  uniformly  in  stable  c(juilib- 
riiiui  of  the  uterus,  and  at  the  same  time  left  it  fre(^  in  its  noi'nuil  ranse  of  move- 
ments. Th(>  principle  was  simjile  and  effective;  it  was  to  unite  to  tiie  anterior 
parietal  peritoneum,  not  the  fundus  or  the  anterior  wall  of  the  corpus  uteri, 
but  the  posterior  wall,  and.  what  is  most  essential,  t(j  tliat  part  of  the  posterior 
wall  just  back  of  the  fundus,  a  surface  about  one-half  inch  back  of  a  line  con- 
nectint;;  the  uterine  ends  of  the  Falloi)ian  tubes.  This  surface  was  united  to 
parietal  i)eritoneum  near  the  uterovesical  reflexion.  Stable  cciuilibrium  and 
permanent  imiform  results  were  secured  by  the;  simple  chang(;  in  the  selection 
of  surfaces  to  be  united  without  denudation  of  the  united  surfaces  and  with 
two  or  three  absorbable  catgut  sutures;  that  is,  very  light  adhesions  (jf  these 
surfaces  were  sufficient.  Moreover,  this  union,  by  lifting  the  posterior  wall 
of  the  corpus  against  the  parietal  peritoneum,  also  served  to  tilt  back  the 
cervix  so  as  to  j^Iace  it  nearer  to  the  hollow  of  the  sacrum — a  most  essential 
mechanical  factor  in  the  correction  of  retroversion,  for  if  the  cervix  he  normally 
near  the  sacrum,  the  corpus  does  not  have  space  in  which  to  retrovert. 

"This  operation,  modified  by  myself  and  others  in  a  personal  experience  of 
several  hundred  cases,  was  in  a  degree  satisfactory  both  as  a  means  of  correcting 
the  dispUicement  and  in  its  freedom  from  the  distressing  mechanical  results 
which  had  discredited  the  obsolete  operation  of  fixation.  It,  however,  may 
give  rise  to  olistruction  of  the  bowel,  for  it  always  leaves  a  more  or  less  con- 
stricted passage  around  the  uterus,  especially  if  the  adhesions  pull  out  into 
cicatricial  bands  under  which  intestine  could  work  its  way  and  be  compressed. 
Such  accidents,  with  grave  results,  have  been  reported  from  time  to  time.  More- 
over, the  operation  in  incompetent  hands,  although  intended  to  produce  light 
adhesions  onlj^,  sometimes  sets  up  union  so  strong  and  cicatricial  as  to  amount 
to  the  much-dreaded  fixation  already  condemned.  These  things  being  so,  I 
finally  disregarded  my  own  satisfactory  results  and  those  of  others,  and  have 
almost  abandoned  the  operation,  and  in  place  of  it  for  several  years  have  sub- 
stituted one  after  another  of  the  various  ligament-shortening  operations. 

"In  taking  leave  of  the  suspension  operation,  which  in  the  evolution  of  the 
subject  has  held  so  large  a  place,  I  pay  it  my  very  appreciative  respects;  it  was 
a  tried  and  trusted  friend ;  it  hardly  ever  failed ;  it  never,  in  my  personal  experi- 
ence, was  followed  by  bad  results  which  I  could  attribute  to  it:  unfortunately, 
however,  it  is  beset  by  the  sentimental  objection  that  it  is  not  anatomical,  and, 
under  indictment  therefore  by  the  surgical  purist  is  charged  with  the  crime  of 
being  unsurgical.  It  may  plead,  however,  extenuating  circumstances,  inasmuch 
as  it  has  suffered  from  the  evil  relations  and  evil  associations  of  fixation,  the 
sins  of  which,  by  confusion  of  the  two  operations,  have  been  visited  on  it  most 
unjustly.  And  so,  not  without  a  sense  of  disloyalty,  I  dismiss,  temporarily 
at  least,  an  old  benefactor,  and  pass  to  the  more  approved  ligament-shortening 
operations. 

"There  is,  perhaps,  more  scientific  indication  for  shortening  the  uterosacral 
than  for  shortening  the  round  ligaments,  because  these  ligaments  should  main- 
tain the  normal  short  distance  between  the  cervix  uteri  and  the  hollow  of  the 
sacrum,  and  l^ecause  shortening  them  therefore  may  fulfil  an  essential  indica- 
tion; but  with  due  respect  for  contrary  opinions  no  uterosacral  operation,  so 
far  as  I  am  aware,  has  been  developed  to  the  degree  of  satisfactory  stable 
results;  that  is,  the  shortened  uterosacral  ligaments  do  not  hold  well.  They 
are  liable  to  pull  out  again  soon  after  the  shortening,  causing  the  operation  to 
fail. 

"Shortening  of  the  broad  ligaments  is  not  germane  to  this  discussion,  except 
as  it  enters  incidentally  into  the  round  ligament  operations. 

"Perhaps  we  may  drop  the  curtain  on  Alexander's  operation,  now  regarded 
as  obsolete.  The  substitute  operation  once  advocated  by  Goldspohn,  while 
reasonably  effective,  I  would  discard  as  requiring  an  unnecessar}^  amount  of 
surgery  for  the  accomplishment  of  the  purpose,  especially  since  this  surger^^ 
might,  in  the  hands  of  an  unlucky  surgeon,  weaken  the  region  of  both  inguinal 


686  DISPLACEMENTS 

canals  and  the  abdominal  rings,  and  thus  give  rise  to  hernia,  to  say  nothing  of 
its  increased  danger  of  sepsis.  The  various  operations  of  doubling  the  round 
ligaments  on  themselves  or  of  suturing  them  in  front  of  the  uterus,  although 
very  useful  in  their  time,  now,  in  the  face  of  more  recent  procedures,  appear 
to  be  passing  into  disuse.  They  always  were  open  to  objection  of  frequent 
inadequacy  for  permanent  results. 

"Perhaps  without  fear  of  much  contradiction  we  may  eliminate  from  serious 
discussion  all  ligament-shortening  operations  except  those  which  belong  to  the 
most  recent  era,  an  era  which  began  with  the  operation  of  Gilliam.  This  opera- 
tion has  been  modified  in  technique  by  Barrett,  myself,  and  others,  and  has 
been  somewhat,  though  perhaps  not  very  materially  improved.  In  addition  to 
the  merit  of  being  anatomical,  and  therefore  surgical,  it  gives  reasonably  perma- 
nent results,  although  possibly  not  so  permanent  as  the  suspension  operations 
of  Kelly,  already  described,  approved,  and  reluctantly  laid  aside.  Gilliam, 
so  far  as  I  am  aware,  took  the  longest  step  toward  placing  the  surgical  treat- 
ment of  retrodisplacements  on  a  scientific  basis.  Just  what  form  of  this  method 
of  supporting  the  uterus  by  drawing  the  round  ligaments  through  other  struc- 
tures and  fastening  them  there  will  stand  the  final  test  of  experience  against 
all  others,  the  future  must  decide.  The  operation  is  not  quite  adequate,  how- 
ever, inasmuch  as  it  fails  like  all  others  of  its  kind  to  hold  the  cervix  back  in 
its  normal  location  near  the  hollow  of  the  sacrum,  an  essential  requirement 
for  perfection  still  unfilled  by  any  method  so  far  proposed. 

"A  radical  departure  from  the  Gilliam  technique,  although  not  entirely 
different  in  principle,  inasmuch  as  it  passes  the  round  hgament  through  other 
structures,  is  the  operation  of  drawing  the  round  ligaments  through  the  broad 
ligaments  and  fastening  them  on  the  posterior  wall  of  the  corpus  uteri.  Clarence 
Webster,  I  think,  first  described  this  operation,  and  therefore  is  entitled  to  the 
credit  of  literary  priority.  I  believe  it  was  earlier  performed  by  Frank  Andrews. 
It  has  been  successfully  championed  by  Baldy.  I  have  performed  it  more 
frequently  than  any  other  for  several  years,  and  so  far  as  I  have  been  able  to 
observe  results,  am  inclined  to  give  it  a  great  deal  of  preference.  This  and  other 
round-ligament  operations  are  thought  to  be  inadequate  and  therefore  contra- 
indicated  when  the  ligaments  are  so  attenuated  as  to  be  incapable  of  giving 
much  support,  and  in  such  cases  many  would  revert  to  the  suspension  operation 
by  adhesion.  I  think  I  would  favor  this  operation  even  with  an  attenuated  liga- 
ment, inasmuch  as  it  carries  along  with  the  ligaments  considerable  peritoneum, 
which  becomes  adherent  and  gives  supporting  power.  In  fact,  the  peritoneal  ele- 
ment in  posterior  attachment  is  a  most  significant  factor — almost  as  significant 
as  it  is  in  ventral  suspension;  it  combines  the  advantages  of  ligament  shorten- 
ing vith  seroserous  adhesions  and  is  free  from  danger  of  resultant  obstruction 
of  the  bowel  so  much  feared  in  the  ventral  suspension  and  the  original  Gilliam 
operation. 

"  The  pessanj,  recognized  in  former  times  as  being  of  great  value,  has  fallen  into 
unmerited  disuse  and  the  correct  application  of  it  has  become  almost  a  lost  art. 
As  a  safeguard  against  recurrences  it  always  should  supplement  any  operation  for 
retrodisplacement  and  shoidd  be  worn  for  at  least  three  months. 

"One  additional  word:  In  this  age  of  dramatic  surgical  achievement  in  the 
abdomen,  let  us  remember  that  our  fathers  of  the  last  generation  developed 
plastic  surgery  on  the  vaginal  side  of  the  pelvic  floor  to  a  surpassing  degree. 
Let  us  keep  in  sight  the  fact  that  any  abdominal  operation  for  retroversion  or 
descent,  however  well  selected  or  performed,  may  be  of  little  avail  against  the 
counter-influence  of  a  relaxed  pelvic  outlet,  and  that  good  plastic  work  below, 
therefore,  may  be  indispensable.  Perhaps  it  is  true  that  the  pioneers  did 
better  plastic  work  than  we  are  doing  now.  It  would  be  interesting  if  under 
the  blinding  influence  of  major  surgery,  plastic  gynecology  should  become  a 
lost  art." 


(H AFTER   XL  1 1 

AXTEVERSIOX  AND  ANTEFLEXION  OF  THE  UTERUS: 
TORSION  OF  THE  UTERUS 

PATHOLOGICAL    ANTEVERSION    OF    THE    UTERUS 

A  CERTAIN  degree  and  condition  of  anteflexion  is  normal.  See 
Normal  Position  and  Normal  Moxements  of  the  Uterus,  The  evils 
of  pathological  anteflexion  are  more  a  matter  of  the  associated  lesions 
than  of  the  displacement  per  se. 

Sometimes  the  physiological  angle  of  flexure  becomes  obliterated  in 
consequence  of  chronic  metritis,  and  results  in  permanent  straighten- 
ing of  the  uterus.  The  cervix  becomes  elevated  and  fixed  above,  or 
the  corpus  depressed  and  fixed  below  the  normal  level.  This  consti- 
tutes pathological  anteversion.    Figure  404. 

Anteversion  is  associated  often  with  pathological  antefiexion.  The 
mobility  at  the  angle  of  flexure  then  is  increased,  diminished,  or  absent; 
the  flexure  is  then  the  significant  factor,  and  will  be  considered  under 
Pathological  Anteflexion. 

Etiology  and  Sjnnptoms  of  Anteversion 

The  causes  of  pathological  anteflexion  may  be  summarized  as  follows : 

1.  Adhesions  in  front  of  the  uterus,  drawing  the  corpus  forward. 

2.  Tumors  behind  the  uterus,  pushing  the  fundus  forward. 
.3.  ^Metritis,  increasing  the  weight  of  the  uterus. 

4.  Small  fibroids  in  the  anterior  wall  of  the  uterus. 

5.  Congenital. 

The  exaggerated  anteversion  of  early  pregnancy  is  physiological; 
the  exaggerated  anteversion  of  the  uterus  in  chronic  metritis  is  patho- 
logical. Elevation  of  the  cervix  and  depression  of  the  corpus  uteri 
may  be  induced  by  peritoneal  adhesions.  Increased  weight  from  a 
mural  myoma  also  may  depress  the  corpus. 

The  symptoms  are  due  to  the  pelvic  inflammations  and  other  com- 
plications already  mentioned.  The  increased  weight  of  the  uterus, 
which  usually  is  hypertrophied  from  metritis,  generally  causes  a  drag- 
ging sensation,  especially  if  the  organ  be  prolapsed.  The  enlarged 
corpus  occupying  the  territory  of  the  bladder  often  induces  persistent 
vesical  irritation,  or  even  cystitis.  Menorrhagia,  when  present,  is  the 
result  of  the  metritis  or  of  a  myoma,  rather  than  of  the  displacement 
itself.  The  symptoms  usually  attributed  to  anteversion  usually  are 
due  rather  to  the  complications  than  to  the  malposition. 

(687) 


DISPLACEMENTS 


Diagnosis  and  Prognosis  of  Anteversion 

The  displacement  is  recognized  by  digital  touch,  which  discloses 
the  anterior  wall  of  the  enlarged  uterus  parallel  to  the  anterior  wall 
of  the  vagina,  with  the  fundus  close  to  the  symphysis  and  the  cervix 
elevated.  Conjoined  examination  will  show  the  size,  shape,  hardness, 
and  degree  of  fixation.  Exaggerated  anteversion  of  the  healthy  uterus 
is  not  necessarily  pathological  in  its  results.  This  is  illustrated  by  the 
anteversion  of  early  pregnancy.  The  prognosis  is  good  if  the  compli- 
cations can  be  removed. 

Figure  404 


Pathological  anteversion.     Mobility  at 


of  flexure  lost. 


Treatment  of  Anteversion 

If  exaggerated  anteversion  is  often  the  position  taken  by  the  uterus 
in  chronic  metritis,  it  follows  that  the  treatment  often  will  be  that 
of  chronic  metritis.  For  the  treatment  of  metritis,  perimetritis, 
myoma,  menorrhagia,  and  other  complications  and  lesions  associated 
with  the  displacement,  see  index  to  those  subjects.  Irritable  bladder, 
which  is  often  a  mechanical  result  of  the  displacement  and  enlarge- 
ment, may  be  relieved  sometimes  by  means  of  an  Albert  Smith  or 
Hodge  pessary,  which  lifts  the  organ  to  a  higher  level  away  from  the 
bladder.  In  thus  elevating  the  uterus  the  anteversion  may  be  increased 
rather  than  diminished.    This  proves  that  the  symptoms  were  dependent 


ANTEVERSION  AND  ANTEFLEXION  OF   THE   UTERUS       OSO 

not  upon  the  aiitcposition,  hut  rather  upon  descent  and  aiitelocation. 
Should  the  parts  be  too  sensitive  to  tolerate  the  hard-ruhher  pessary 
or  a  flexible  rubber  ring,  the  daily  application  of  medicated  {)Ie(lf;ets  of 
lambs'  wool  may  ^nve  sui)j)ort  to  the  uterus  and  decrease  tenderness 
until  the  more  j)ermanent  instrument  can  be  worn.  The  numerous 
anteversion  pessaries  designed  to  elevate  the  corpus  by  direct  pressure 
on  the  anterior  wall  of  the  uterus  p;enerally  irritate  the  organ  and  thereby 
aggravate  the  inflammatory  com{)lications.  They,  therefore,  are  to  be 
condemned. 

Figure  405 


Congenital  anteflexion;  both  cervix  and  corpus  uteri  bent  forward. 

PATHOLOGICAL  ANTEFLEXION  OF  THE  UTERUS 

A  comprehensive  study  of  pathological  anteflexion  would  have  to 
take  into  account  the  abnormal  conditions  usually  associated  with  it; 
these  may  have  the  relation  of  cause  or  effect,  or  be  a  concurrent 
result  of  some  common  cause. 

A  distinction  between  normal  and  pathological  anteflexion  would 
show  that  an  essential  factor  in  the  former  is  mobility  at  the  angle  of 
flexure  which  permits  the  degree  of  flexure  to  vary  within  certain 
defined  limits.  The  limit  of  normal  anteflexion  is  approximately  90 
degrees.  The  physiological  variation  is  somewhat  commensurate  w^th 
the  varying  quantity  of  fluid  in  the  bladder. 
42 


690  DISPLACEMENTS 

The  body  of  the  uterus  rests  upon  the  bladder,  and  must  rise  as  the 
bladder  becomes  distended.  Conversely,  if  the  urine  be  drawn  through 
a  catheter,  even  while  the  woman  is  lying  on  the  back,  the  corpus, 
notwithstanding  the  opposing  influence  of  its  own  weight,  immediately 
follows  the  receding  wall  of  the  bladder  and  returns,  through  an  angle 
of  45  degrees  or  possibly  even  90  degrees,  to  its  accustomed  position. 

The  normal  forward  bending  of  the  corpus  upon  the  cervix  uteri 
when  the  bladder  is  empty  makes  an  angle  of  which  the  approximate 
physiological  limits  are  between  45  degrees  and  90  degrees;  the  flexure, 
therefore,  would  generally  be  pathological  if  less  than  45  degrees 
or  more  than  90  degrees.  Furthermore,  if  the  flexure,  whether  it  be 
normal  or  abnormal  in  extent,  does  not  disappear  upon  filling  the 
bladder,  but  remains  constant  under  all  conditions,  the  rigidity  makes 
the  flexure  pathological. 

Anteflexion  is,  therefore,  pathological  if  the  mobility  at  the  angle 
of  flexure  is  increased  or  diminished,  or  absent. 

Etiology  and  Classification  of  Anteflexion 

Anteflexion  may  be  either  congenital  or  acquired. 

Congenital  and  Developmental  Anteflexion.^The  uterus  in  this  form 
of  anteflexion  is  bent  upon  itself  almost  double,  the  body  and  the 
cervix  both  pointing  in  the  direction  of  the  pelvic  outlet.  The  cervix 
is  somewhat  elongated  and  situated  in  the  long  axis  of  the  vagina. 
See  Figure  405.  The  cause  may  be  defective  foetal  development,  or 
failure  of  the  immature  child  uterus  to  develop  at  puberty,  a  failure 
which  usually  pertains  also  to  the  Fallopian  tubes,  ovaries,  and  vagina. 
A  more  proper  name  is  infantfle  uterus. 

Acquired  Anteflexion  may  be  simply  an  exaggeration  of  the  normal 
flexure,  due  either  to  increased  weight  of  the  corpus  from  the  presence 
of  a  myoma  near  the  fundus,  or  to  unequal  growth  of  the  uterine  walls, 
or  to  unequal  involution,  or  to  an  abnormally  soft,  mobile  condition 
of  the  uterine  walls.  A  not  infrequent  cause  of  anteflexion  is  thick- 
ening of  the  posterior  wall  of  the  uterus  from  the  products  of  inflamma- 
tion, and  a  corresponding  atrophy  of  the  anterior  wall  from  prolonged 
pressure  at  the  angle  of  flexure.  This  condition  is  apt  to  be  associated 
with  post-uterine  inflammation  involving  the  uterosacral  ligaments,  a 
frequent  and  discouraging  complication.  Sometimes  the  inflamed 
ligaments  contract  and  drag  the  anteflexed  uterus  upward  and  back- 
ward, where  it  may  be  flxed  permanently  in  its  posterior  location  by 
peritoneal  adhesions. 

Pathology  of  Anteflexion 

Peri-uterine  inflammations  having  the  relation  of  either  cause  or 
effect  to  the  flexure,  often  bind  the  pelvic  organs  together  in  a  mass 
of  exudate,  with  resulting  failure  of  nutrition,  nerve  irritation,  and 
constant  pain,  which  sometimes  render  the  patient's  life  miserable 


ANrEVf'Jh'SlOX   AM)   ANTEFLEXION  OF   THE   VTEIU'S       i\S)\ 

and  useless.  Constriction  or  ('oll;ii)se  of  the  uterine  canal  at  the  point 
of  flexure  may,  by  confining  the  secretions  above,  produce  inflamma- 
tion in  the  body  of  the  uterus,  Fallopian  tubes,  and  ovaries.  Tliis  is 
analojious  to  the  cystitis,  urethritis,  pyelitis,  and  nei)hritis  which  fol- 
low stricture  of  the  male  urethra.  As  the  fecal  matter  i)asses  the 
cervix  during  defecation,  force  is  applied  to  the  posterior  cervical  wall 
in  the  direction  of  the  lower  arrow.  Figure  -iO(J.  At  the  same  time 
fixation  of  the  abdominal  muscles  due  to  straining,  whether  in  urina- 
tion or  defecation,  results  in  the  application  of  force  upon  the  corpus 
uteri  in  the  direction  of  the  uj)per  arrow.  Thus  the  flexure  is  increased 
and  perpetuated  with  defecation  and  urination. 

Figure  406 


The  arrows  show  the  influence  on  the  displacement  of  the  forces  produced  by  straining  at  stool. 


Sjrmptoms,  Course,  and  Complications  of  Anteflexion 

The  numerous  symptoms  due  to  the  inflammatory  and  other  com- 
plications should  not  be  confounded  with  those  that  directly  depend 
upon  the  displacement.  The  symptoms  of  anteflexion  usually  may  be 
referred,  first,  to  the  bladder  and  urethra;  and,  second,  to  the  uterus 
itself. 

The  Vesical  and  Urethral  Symptoms  are  produced  either  by  rigidity 
of  the  uterine  tissue  at  the  angle  of  flexure,  which  prevents  the  corpus 
uteri  from  rising  out  of  the  way  of  the  filling  bladder;  or  by  inflam- 
matory shortening  of  the  uterosacral  ligaments,  which,  by  drawing 
the  uterus  upward  and  backward,  puts  the  vesicovaginal  wall  on  the 


692 


DISPLACEMENTS 


stretch;  this  causes  traction  upon  the  neck  of  the  bladder  and  conse- 
quent bladder  and  urethral  irritation,  and  may  be  the  starting-point 
of  cystitis  and  urethritis. 

Vesical  irritation  caused  by  post-uterine  inflammation  and  conse- 
quent contraction  of  the  uterosacral  ligaments  often  is  attributed 
wrongly  to  the  mechanical  pressure  of  the  anteflexed  corpus  uteri  upon 
the  bladder;  this  is  manifestly  impossible,  for  the  contracted  utero- 
sacral supports  hold  the  entire  uterus  far  away  from  the  bladder. 

Uterine  Symptoms. — When  the  flexure  has  gone  beyond  the  normal 
limit  and  has  become  pathological,  two  principal  results  may  occur, 
especially  if  there  be  immobility  at  the  angle  of  flexure. 

1.  Collapse  of  the  blood-vessels  at  the  angle  of  flexure,  with  conse- 
quent obstruction  of  the  circulation,  passive  congestion,  and  hyper- 
secretion of  vitiated  mucus. 

Figure  407 


Acquired  anteflexion  with  post-uterine  fixation.    Want  of  mobility  at  angle  of  flexure. 

2.  Collapse  and  obstruction  of  the  uterine  canal  at  the  angle  of 
flexure,  with  consequent  retention  of  the  uterine  secretions.  The  secre- 
tions may  decompose  and  become  a  potent  source  of  irritation;  the 
uterine  mucosa  could  then  neither  perform  its  normal  part  in  men- 
struation nor  furnish  a  safe  resting-place  for  the  impregnated  ovum. 
The  possible  symptom-group  dependent  upon  these  two  forms  of 
obstruction  includes  endometritis,  dysmenorrhoea,  and  sterility. 


ANTEVERSrnx   A  XI)  AXTEFLEXIOX  OF  THE   FTERrS       093 

Endometritis  may  be  caused  and  perpetuated  by  tlie  endometrial 
anil  vascular  obstruction.  The  causation  of  rhinitis  from  o})struction 
in  the  nasal  passages  and  of  cystitis  from  stricture  of  the  urethra  is 
analogous. 

DilsnicuDrrhoea  may  depend  upon  collapse  and  constriction  of  the 
uterine  canal  at  the  angle  of  flexure.  This  causes  the  blood  to  accu- 
mulate and  to  coagulate  in  the  body  of  the  uterus,  from  which  it  is  ex- 
pelled at  inter\als  by  uterine  contractions  simulating  labor  pains.  Pain 
when  due  to  this  cause  is  therefore  always  esi)ecially  severe  just  before 
the  passage  of  a  clot.  Dysmenorrhoea  may  also  be  caused  by  similar 
collapse  and  consequent  obstruction  in  the  veins  at  the  angle  of  flexure ; 
this  causes  intense  venous  congestion  of  the  entire  body  of  the  uterus; 
pain  then  is  due  to  pressure  of  the  swollen  vessels  upon  the  nerve- 
filaments  and  to  a  consequent  irritable  condition  of  the  muscular  tissue 
of  the  uterus.  Sometimes  the  uterine  canal  becomes  temporarily 
straightened  with  the  establishment  of  the  flow;  this  removes  the  cause 
of  the  vascular  obstruction,  and  the  pain  from  congestion  is  relieved. 
It  is  clear  that  the  pain  would  be  intensified  in  a  uterus  hypersensitive 
from  metritis,  and  especially  from  neuritis. 

Sterility  is  consequent  not  so  much  upon  failure  of  impregnation, 
as  upon  the  fact  that  the  ovum,  if  impregnated,  is  unable  to  survive 
in  the  hostile  environment  of  an  infected  endometrium.  It  is  often 
maintained  that  the  constriction  in  the  uterine  canal  per  se  prevents 
the  entrance  of  spermatozoa,  and  therefore  causes  the  sterility.  This 
in  a  measure  may  be  true;  but  endometritis  which  often  results  from 
obstruction  is  the  more  direct  and  frequent  cause  of  sterility. 


Diagnosis  of  Anteflexion 

Before  the  distinction  was  made  between  physiological  and  patho- 
logical anteflexion,  it  was  usual  to  treat  all  anteflexions  as  pathological. 
The  reaction  came,  and  with  it  a  universal  proposition  that  anteflexion 
had  no  pathological  signiflcance  yer  se;  that  it  was  wholly  a  question 
of  the  associated  lesions.  But,  like  other  universal  propositions,  this 
one  was  too  sweeping;  it  did  not  take  into  account  pathological 
anteflexion. 

The  educated  touch  which  distinguishes  the  normal  version,  flexion, 
and  movements  of  the  uterus  "udll  appreciate  the  anatomical  dift'erences 
between  pathological  and  normal  anteflexion.  The  degree  of  flexure, 
the  mobility  or  rigidity,  and  the  size,  shape,  location,  and  consistence 
of  the  uterus  may  be  ascertained  by  conjoined  manipulation.  The 
presence  of  post-uterine  inflammation  is  recognized  by  the  pain  caused 
in  drawing  the  uterus  slightly  forward,  and  by  the  increased  thickness 
and  tenderness  which  may  be  felt  by  vaginal  or  rectal  touch  in  the 
region  of  the  uterosacral  ligaments.  Anteflexion  is  distinguished  from 
myoma  in  the  anterior  wall  of  the  uterus  by  conjoined  examination 
and  the  sound.     The  common  error  of  mistaking  the  normal  version 


694 


DISPLACEMENTS 


and  flexion  of  a  prolapsed  uterus  for  pathological  version  and  flexion 
should  be  avoided. 

Congenital  anteflexion  will  be  characterized  by: 


The  small  size  of  the  uterus. 

The  small  or  pin-hole  os  uteri. 

The  relative  lengths  of  the  corpus  and  cervix  uteri;  the  corpus 
is  one-third  and  the  cervix  is  two-thirds  the  length  of  the 
entire  uterus.  The  reverse  of  these  measurements  is  true  of 
the  fully  developed  uterus.    See  Chapter  I. 

Figure  408 


Myoma  on  the  anterior  uterine  wall,  simulating  anteflexion. 

Acquired   anteflexion  will    be   recognized   by   one   or   more  of   the 
following  conditions: 

1.  Resisting  bands  behind  the  uterus. 

2.  Downward  and  forward  direction  of  the  cervix  uteri  in  the 

long  axis  of  the  vagina. 

3.  Flexure  of  the  corpus  uteri  upon  the  cervix;  the  angle  of  flexure 

is  easily  palpated  in  front  of  the  cervix. 


Treatment  of  Anteflexion 

The  treatment  is  directed,  first,  to  the  complications;  second,  to 
the  mechanical  indications  for  straightening  the  flexed  uterus. 


ANTEVKRSION   AND   AXTKFLEXIOX   OF   THE   UTERUS       095 

The  Treatment  of  the  Comphcations.  If  there  l)e  inflammation 
of  the  uterus  and  its  surroun(Uii[;s,  in  the  rehition  of  either  cause  (^r 
effect  to  the  displacement,  its  successful  treatment  becomes  the  prime 
indication,  because,  unless  treated,  it  is  a  contraindication  to  the  more 
direct  treatment  of  the  malposition  itself.  It  may  be  necessary  to 
remove  a  tumor  or  to  separate  adhesions.  Incurable  chronic  metritis 
may  render  all  direct  treatment  useless.  Improvement  in  the  general 
health,  treatment  of  other  complications,  and  palliation  then  become 
the  only  resources. 

Before  considering  the  various  recognized  measures  for  the  direct 
treatment  of  the  flexure  itself,  it  is  important  to  exclude  all  cases  of 
normal  anteflexion.  It  would  be  clearly  absurd  to  treat  normal  ante- 
flexion for  dysmenorrhoea  or  sterility. 

Figure  409 


Treatment  of  anteflexion  by  massage. 


The   Mechanical   Indication,   when   the   flexure   is   pathological,   is 
clearly  to  straighten  the  uterus,  so  that: 

a.  The  uterus  may  be  out  of  the  range  of  the  forces  indicated  by 
the  arrows  in  Figure  406. 

b.  The  circulation  may  be  relieved. 

c.  The  uterine  canal  may  perform  its  natural  functions  as  a  drainage- 
tube. 


696 


DISPLACEMENTS 


The  mechanical  treatment  includes  the  following  measures: 

1.  The  pessary. 

2.  Local  massage. 

3.  Electricity.  ' 

4.  Forcible  dilatation. 

5.  Posterior  division  of  the  cervix. 

6.  The  author's  operation. 

1.  The  Pessary. — The  various  anteflexion  and  anteversion  pessaries 
that  have  been  devised  for  the  purpose  of  propping  up  the  corpus 
are  almost  useless.  Their  questionable  reputation  depends  upon  the 
relief  they  frequently  give  to  complicating  prolapse,  the  symptoms  of 
which  have  been  attributed  wrongly  to  anteflexion  and  anteversion. 
If  pessaries  are  indicated  at  all,  therefore,  they  may  be  used  upon 
the  same  principle  as  in  descent.  (See  Treatment  of  Descent.)  Intra- 
uterine stem-pessaries  designed  to  straighten  the  flexed  uterus  are 
sometimes  effective — always  dangerous. 

Figure  410 


Posterior  division  of  the  cervix  uteri;  lines  of  incision  in  flexion  of  the  uterus.     Sims'  operation. 


2.  Local  Pelvic  Massage  applied  during  menstruation  and  in  the 
intermenstrual  period  has  some  value  for  the  temporary  relief  of 
dysmenorrhoea  due  to  anteflexion.  The  treatment  consists  of  pushing 
the  cervix  upward  and  backward  with  the  left  index-finger,  while  with 
the  right  hand  a  forward  and  downward  pressure  is  exerted  on  the 
organ;  this  converts  for  the  time  the  anteflexion  into  an  extreme  ante- 
version. The  method  is  illustrated  by  Figure  409.  When  the  displace- 
ment is  associated  with  dysmenorrhoea  the  massage  may  be  continued 


A.WTEVERSIOX  AXD  ASTEFLEXIOS  OF   THE   CTERL'S       097 

durijij;    menstruation,  and    in   some   cases  with  ^reat  and    immediate 
relief.      It  should   he   continued   tor  at   least  a  lunnher  of  weeks. 

3.  Electricity  is  said  hy  the  advocates  of  it  to  he  a  useful  aj^ent; 
it  is,  howe\er,  hy  no  means  efl'ective  enough  to  .stand  alone  as  the 
accepted  treatment  of  patholo<;ical  anteflexion.  After  considerahle 
personal  experience  the  writer  has  discarded  it. 

4.  Forcible  Dilatation. — This  operation,  usually  associated  with 
curettage,  is  described  in  Chapter  \.  It  is  indicated  in  anteflexion 
with  collapsed  or  stenosed  uterine  canal  and  associaterl  endometritis, 
dysmenorrh(ea,  or  sterility. 

Figure  411 


The  posterior  wall  of  the  cennx  being  divided  by  scissors. 

The  following  is  an  abstract,  with  some  modifications,  of  a  valuable 
contribution^  by  Goodell,  in  which  he  gives  positive  indorsement  to 
rapid  dilatation  as  proposed  by  Ellinger  and  others.  The  instruments 
used  are  two  Ellinger  dilators,  which  are  recommended  on  account  of 


'  American  Journal  of  Obstetrics,  1S84,  p.  1179. 


698 


DISPLACEMENTS 


the  parallel  action  of  their  blades.  The  dilatation  is  begun  with  the 
smaller  instrument  and  completed  with  the  larger.  The  larger  instru- 
ment has  powerful  blades  that  do  not  spring  nor  feather.  The  light 
instrument  has  only  a  ratchet  in  the  handle;  but  the  stronger  one  has 
a  screw  that  forces  the  handles  together  and  the  blades  apart.  To 
prevent  injury  to  the  fundus  when  the  instrument  is  open,  the  length 
of  the  blades  is  limited  to  two  inches.     The  larger  instrument  has  a 

Figure  412 


The  cut  surfaces  held  apart  by  tenacula.  The  dotted  lines  show  wedge-shaped  pieces  to  be  removed 
by  scissors,  in  order  to  make  the  cut  surfaces  more  readily  fold  upon  themselves.  Sutures  designed  to 
fold  cut  surfaces  on  themselves  in  place,  but  not  tied. 


dilating  capacity  of  one  and  a  half  inches,  and  has  a  graduated  arc 
in  the  handles  to  indicate  the  divergence  of  the  blades.  Goodell's 
modification  of  Ellinger's  dilator  is  provided  with  serrated  blades,  to 
keep  them  from  slipping  out  of  the  canal  during  the  process  of  dilatation. 
For  dysmenorrhoea  or  sterility  due  to  flexion  or  stenosis  the  method 
of  operation  is  as  follows:  The  patient  etherized,  and  the  uterus 
exposed  by  Sims'  speculum.  The  cervix  is  held  by  a  tenaculum,  and 
the  smaller  dilator  is  introduced  as  far  as  it  will  go.    Upon  gently 


ANTEVERSIOX    A.\D   AXTEP'LEX lO.X   OF   THE    I  TEltlS       (li)9 

stretcliin<,'  open  that  portion  of  tlic  uterine  eanal  whieh  it  occupies, 
the  stricture  above  so  yields  that  when  the  blades  are  closed  they 
will  pass  hijiher.  By  repeating  this  manoeuvre  a  cervical  canal  is  tun- 
nelled out  where  before  not  e\en  a  fine  j)robe  couhl  be  passed.  Should 
the  OS  externum  or  c-er\ical  canal  be  too  small  to  admit  the  instru- 
ment, a  pair  of  pointetl  scissors  may  be  substituted,  and  by  the  same 
openin<>;  and  closiufj;  motions  the  canal  may  be  prepared  for  the  intro- 
duction of  the  smaller  dilator.    As  soon  as  the  cavity  of  the  uterus  has 


Figure  413 


-^^^^^'^ 


Suture  shown  in  Figure  412  tied,  and  additional  sutures  designed  to  fortify  this  one  also  introduced 
and  tied.     This  ordinarily  completes  the  operation. 


been  entered  the  handles  are  brought  together.  This  dilator  is  then 
withdrawn,  the  larger  one  introduced,  and  its  handles  slowly  screwed 
together.  If  the  flexure  be  very  marked,  the  larger  instrument,  after 
being  withdraw' n,  should  be  reintroduced  with  its  curve  in  the  direction 
opposite  to  that  of  the  flexure,  and  the  final  dilatation  made  with  the 
dilator  in  this  position;  but  in  reversing  the  curve  the  operator  should 
take  care  not  to  rotate  the  organ  upon  its  own  axis,  and  not  to  mistake 
a  twist  thus  made  for  a  reversal  of  the  flexure.    The  ether  is  then  with- 


700  DISPLACEMENTS 

held,  and  the  instrument  allowed  to  remain  in  place  until  the  patient 
begins  to  flinch,  when  it  is  removed.  The  best  time  for  the  dilatation  is 
midway  between  the  monthly  periods.  In  the  majority  of  cases  the  dila- 
tation should  be  carried  to  about  one  and  a  quarter  inches.  The  infantile 
uterus  that  has  failed  to  develop  at  puberty  has  thin,  unyielding  walls, 
and  should  therefore  not  be  dilated  more  than  three-fourths  of  an  inch 
to  an  inch.  In  using  the  larger  instrument  it  is  usually  necessary  to  have 
the  assistant  make  decided  countertraction  with  the  vulsella  forceps 
to  keep  the  blades  of  the  dilator  from  slipping  out.  The  cervix  is  some- 
times lacerated,  but  not  sufficiently  to  produce  unpleasant  results. 
Goodell's  statistics  include  150  operations  of  full  dilatation  under 
ether,  with  no  fatal  result  and  without  serious  inflammatory  dis- 
turbance. 

After  forcible  dilatation  under  ether  the  c-ervical  canal  may  remain 
relatively  open  and  straight,  and  a  symptomatic  cure  may  be  effected. 
Too  often,  however,  the  canal  returns  to  its  previously  angular  condi- 
tion, and  the  dysmenorrhoea  and  sterility  continue.  The  comparative 
safety  of  forcible  dilatation  in  the  hands  of  a  skilful  and  experienced 
gynecologist  may  be  contrasted  with  its  great  danger  when  undertaken 
by  a  careless  septic  operator  unacquainted  with  the  special  require- 
ments of  uterine  surgery.  Peri-uterine  inflammation  is  considered 
ordinarily  a  contraindication  to  the  operation. 

Dilatation  by  means  of  tents  is  transient  in  its  result  and  dangerous 
to  life.  The  operation  has  given  frequent  and  serious  warnings,  in  the 
shape  of  pelvic  infections,  which,  if  not  destructive  to  life,  have  been 
overwhelmingly  disastrous  in  their  influence  upon  health. 

5.  Posterior  Division  of  the  Cervix  Uteri  is  an  operation  devised  and 
once  extensively  practised  by  Marion  Sims  and  his  followers;  it  was 
designed  to  straighten  the  uterine  canal  by  making  a  direct  outlet 
from  the  point  of  flexure  directly  through  the  posterior  wall  of  the  cervix. 
The  operation  was  not  without  merit,  but  it  fell  into  disrepute  because, 
first,  it  was  done  often  in  normal  anteflexions;  and  second,  because 
while  it  overcame  the  obstruction  in  the  uterine  canal,  it  did  not 
straighten  the  uterus  and  so  relieve  the  more  important  obstruction  in 
the  blood-vessels.  Moreover,  the  divided  cervix  was  prone  to  reunite 
and  leave  a  cicatricial  contraction  at  the  os  externum.  The  operation 
was  in  the  right  direction,  but  was  inadequate. 

6.  The  Author's  Operation/  about  to  be  described,  has  for  its  object 
the  utilization  of  dilatation  and  of  posterior  division  of  the  cervix  in 
such  a  way  as  not  only  to  enlarge  the  calibre  of  the  uterine  canal,  but 
also  to  straighten  the  uterus  and  thereby  overcome  the  circulatory 
obstruction.    The  operation  is  performed  as  follows: 

Everything  connected  with  the  operation  has  been  rendered  surgi- 
cally clean.  The  patient  being  under  ether,  the  uterus  is  exposed  by 
Sims'  speculum.  The  uterine  canal  is  dilated  by  means  of  a  Palmer 
dilator,   followed   by   an   Ellinger   dilator,  sufficiently   to   permit   the 

1  E.  C.  Dudley.  "A  Plastic  Operation  Designed  to  Straighten  the  Anteflexed  Uterus,"  American 
Journal  of  Obstetrics,  1891,  No.  2,  vol.  xxiv. 


ANTEVERSION  AND  ANTKFlJ'LXIoy  OF   THE   VTERVS       701 

introduction  of  a  small  sharp  curette,  hut  not  necessarily  to  the  extent 
advocated  hy  (ioodell.  Curettage  is  performed  as  directed  in  ( 'hapter 
XM.  for  endometritis.  The  curettage  may  give  only  negative  results, 
and  may  he,  therefore,  simply  exploratory;  or  it  may  give  evidence  of 
pronounced  endometritis.  If  the  latter,  it  is  im])erati\e  as  a  preliminary 
aseptic  step,  not  only  to  the  plastic  part  of  the  operation,  but  also  as  a 
curati\e  measure. 

Figure  414 


Anterior  lip  excised  and  sutures  in  place  ready  to  tie. 

The  cervix  is  divided  with  scissors  backward  in  the  median  line  past 
the  uterovaginal  attachment  nearly  to  the  uteroperitoneal  fold  in  the 
pouch  of  Douglas.     See  Figure  411. 

The  cut  surfaces  thus  incised  then  are  held  widely  apart  by  means 
of  two  tenacula  in  the  hands  of  an  assistant;  the  incision  is  somewhat 
deepened  by  means  of  a  scalpel,  especially  in  the  uterine  wall  next  to 
the  cervical  canal,  and  a  small  angle  is  cut  out  on  either  side,  as  shown 
by  the  dotted  lines  in  Figure  412.  The  cut  surface  on  each  side  is  now 
folded  on  itself  by  a  single  silkworm-gut  suture,  as  shown  in  Figure 
412.    This  suture  is  tied  and  fortified  by  interrupted  sutures  on  either 


702 


DISPLACEMENTS 


side.  The  lines  of  union  thus  made  are  shown  in  Figure  413.  By  means 
of  these  sutures  the  os  externum  is  carried  directly  back  to  the  angle 
of  the  incision.  The  cervix  now  points  backward  in  its  normal  direction 
toward  the  hollow  of  the  sacrum,  instead  of  forward  toward  the  vaginal 
outlet.    See  Figure  404. 

Figure  415 


Sutures  tied  and  operation  complete,  both  on  posterior  and  anterior  lips. 


In  some  cases  of  extreme  anteflexion  there  is  a  disproportionately 
long  anterior  lip,  which  is  the  result  of  a  relatively  greater  pressure 
on  the  posterior  lip  by  the  posterior  vaginal  wall;  this  elongated  lip 
should  be  caught  with  the  tenaculum  and  partially  removed  by  the 
scissors.  The  incised  surface  is  then  closed  upon  itself  with  sutures  as 
shown  in  Figures  414  and  415.  The  dotted  line  in  Figure  406  shows 
in  section  the  line  of  incision  through  the  protruding  lip:  the  incision 
should  extend  to,  but  not  into,  the  os  externum.  This  part  of  the  opera- 
tion is  not  required  unless  the  anterior  lip  decidedly  protrudes,  and 
therefore  usually  is  omitted.  The  removal  of  a  portion  of  the  lip  in  a 
suitable  case  is  not  only  not  a  mutilation,  but  it  even  contributes  to  the 
straightening  of  the  uterus. 


AXTEVERSITON  AND  ANTEFLK.K lO.X  OF   THE   I'TElil'S       703 

Conjoined  examination  upon  conipletion  of  the  oj)erati<)n  in  each  of 
the  author's  cases  has  shown  in\ariably  the  uterus  either  to  have  been 
straightened  or  the  anteflexion  to  have  been  reduced  to  a  degree  (juite 
within  i)hysiolo,ii,ical  hniits.  The  results  have  l)een  substantially  the 
same  whether  the  point  of  flexure  was  at  the  os  internum  or  below  it. 

The  two  posterior  lines  of  sutures  have  the  effect  of  transplanting 
the  OS  externum  to  the  very  angle  of  the  posterior  incision.  The  an- 
terior sutures,  if  used,  have  the  effect  of  carrying  the  cervix  back  by 
a  distance  e(inal  to  one-half  the  length  of  the  anterior  cut  surface, 
which  is  doubled  upon  itself.  By  these  means  a  permanent  change, 
quite  equal  to  overcoming  the  flexure,  is  effected  in  the  direction  of  the 
cervix.  xA.s  the  result  of  the  anterior  portion  of  the  operation,  the  uterus 
in  a  suitable  case  is  lifted  also  in  a  higher  plane  in  the  pelvis,  where  it 
ceases  to  be  a  mechanical  irritant  to  the  bladder.  This  portion  of  the 
operation  may  therefore  be  indicated  for  descent  when  complicated  with 
anteflexion. 

The  writer  has  not  undertaken  this  operation  on  the  small,  unde- 
veloped infantile  uterus.  The  so-called  congenital  anteflexion  is  only 
one  factor  in  a  general  failure  of  development,  a  failure  that  pertains 
not  to  the  uterus  and  other  reproductive  organs  alone,  but  to  the  gen- 
eral system.  The  amenorrhoea  or  very  scanty  menstruation  and  the 
sterility  usually  associated  with  this  condition,  being  only  the  local 
expressions  of  faulty  general  development,  are  not  reached  by  any 
uterine  treatment,  surgical  or  non-surgical. 

This  operation  was  published  first  in  November,  1890.^  At  that 
time  the  writer  reported  eighteen  cases.  The  results  w^ere  classified 
under  two  heads,  one  for  the  mechanical  and  for  the  symptomatic 
results.  The  mechanical  result  was  invariably  a  satisfactory  straight- 
ening of  the  uterus.  The  symptoms  were  relieved  satisfactorily  in 
about  three-fourths  of  the  cases.  The  author's  personal  experience 
with  this  operation  now  numbers  about  one  hundred  cases.  With  this 
larger  ex-perience  and  larger  observation  of  the  symptomatic  results 
he  is  able  to  verify  the  conclusions  formed  when  the  operation  was 
given  to  the  profession.  In  no  case  has  the  operation  failed  to  give 
an  anatomical  cure,  and  the  symptomatic  results  have  been  satisfactory 
in  about  75  per  cent,  of  all  cases. 

The  symptomatic  indication  in  the  great  majority  of  cases  was  dys- 
menorrhoea.  This  symptom,  when  the  flexure  was  uncomplicated  by 
peri-uterine  inflammation — that  is,  when  the  conditions  were  mechan- 
ical— has  been  quite  generally  relieved.  In  seven  cases  the  indication 
was  prolonged  sterility.  In  three  of  these  cases  normal  parturition 
has  taken  place. 

R.  G.  Wadsworth,^  of  Boston,  reports  31  cases  for  which  the  opera- 
tion was  performed  by  himself  and  other  operators  in  the  Free  Hospital 
for  Women,  in  Boston,  and  10  cases  occurring  in  the  private  practice 
of  Dr.  Reynolds,  and  37  cases  from  the  literature.    Generally  speaking, 

'  Paper  by  E.  C.  Dudley,  read  before  the  New  York  Obstetrical  Society,  November  18,  1890. 
2  The  Bulletin  of  the  Free  Hospital  for  Wonien. 


704  DISPLACEMENTS 

the  results  of  the  operation  for  all  these  cases,  both  anatomically  and 
symptomatically,  were  substantially  the  same  as  for  the  series  of  cases 
originally  reported  by  the  author. 

The  operation  is  not  presented  as  a  panacea  for  all  the  maladies  of 
pelvic  origin  in  which  there  happens  to  be  a  pathological  anteflexion. 
Cases  are  numerous  in  which  anteflexion  is  rather  an  incidental  than 
an  essential  factor.  The  hope  is  that  the  operation  may  prove  of  value 
when  the  indication  to  be  fulfilled  is  wholly  or  in  part  mechanical. 

There  is  danger  that  this  operation  will  be  performed  indiscrimi- 
nately in  cases  not  of  pathological,  but  of  physiological  anteflexion. 
On  the  other  hand,  those  who  do  not  consider  anteflexion  as  having 
any  pathological  significance  2;er  se,  and  do  not  always  make  the  dis- 
tinction between  the  physiological  and  pathological  position,  will  fail 
to  appreciate  the  mechanical  indication,  and  will  therefore  discard  the 
operation  altogether.  Clearly  a  woman  might  have  anteflexion  and, 
if  it  were  normal,  might  have  a  large  variety  of  lesions  wholly  inde- 
pendent of  it.  To  say  this,  after  all,  might  be  sa^dng  only  that  a  woman 
may  have  a  variety  of  pathological  developments  in  the  pelvis,  and  at 
the  same  time  have  the  uterus  in  its  normal  position.  Normal  ante- 
flexion could,  of  course,  have  no  pathological  significance. 

Since  the  investigations  of  Schultze  and  others,  we  may  readily 
distinguish  pathological  antefiexion,  in  which  the  uterus  is  bent  to  the 
point  of  producing  two  kinds  of  obstruction  at  the  angle  of  flexure: 
1.  Obstruction  of  the  canal  from  collapse  of  the  canal.  2.  Obstruction 
of  the  blood-vessels  from  collapse  of  the  blood-vessels.  Under  such 
conditions  uterine  congestion  and  catarrh,  as  pointed  out  in  the  fore- 
going paragraphs,  are  apt  to  follow,  normal  physiological  changes  can- 
not take  place  either  in  the  decidua  of  menstruation  or  in  the  decidua 
of  pregnancy;  hence,  menstrual  disorders  and  sterility. 

The  mechanical  indication  is  clear;  straighten  the  uterus  and  thereby 
relieve  the  obstruction  in  both  the  uterine  canal  and  the  vessels. 

The  operation  is  not  a  substitute  for  dilatation  and  curettage,  but 
rather  supplementary  to  these  two  procedures. 

The  writer  has  practised  extreme  divulsion  with  curettement  in 
many  cases  of  anteflexion;  but  the  results  were  not  very  satisfactory. 
They  are,  however,  more  gratifying  when  the  plastic  operation  already 
described  is  added  to  the  dilatation  and  curettage. 

If  it  is  wrong  to  treat  anteflexion  mechanically,  because  it  is  a  result 
of  certain  associated  lesions,  it  follows  that  retroflexion  and  all  other 
displacements  should  not  be  treated  mechanically,  because  they  also 
are  equally  the  result  of  associated  lesions.  This  almost  amounts  to 
the  reductio  ad  ahsurdum. 

One  hears  much  of  inflammation  of  the  uterosacral  ligaments  as  the 
great  associated  lesion  in  pathological  anteflexion,  and  yet  is  disap- 
pointed often  in  his  search  for  evidence  of  such  inflammation.  In- 
flammation often  exists  there,  but  in  a  large  proportion  of  such  cases 
it  has  passed  away,  leaving  pathological  anteflexion  as  a  permanent 
result. 


ANTEVERSinx  A\D  AXTEFLEXIOX  OF   THE   UTERUS       705 

In  a  few  cases  of  anteflexion  low  down  in  the  eer\ix  the  author  with 
good  anatomical  and  s\  niptomatic  results  has  substituted  Schroeder's 
operations  for  his  own. 

Si)U'e  plariiKj  this  antrflrxion  ojx'rnfion  before  the  pwfe.s.s-lon  in  ],S9(), 
it  has  been  the  subject  of  nninerous  rntieal  reports  front  surf/eons  who  hate 
given  it  more  or  less  exteusice  trial  both  at  home  and  abroad.  A  f/ratifyinr/ 
fact  is  that  these  reports  usually  have  been  favorable  and  have  substaniialli/ 
coincided  with  my  own  early  statistics,  and  singularly  have  verified  my  own 
observations  of  twenty-three  years.  Personally  I  hare  avoided  any  discus- 
sioti  of  the  operation  during  this  time,  deeming  it  wise  to  let  the  operation 
stand  or  fall  on  its  own  merits.  A  notable  paper  on  this  subject  apjpeared 
from  the  pen  of  Dr.  Samuel  M.  Brickner,^  Associate  Cynerologi.st  in  Mount 
Sinai  Hospital,  New  York.  This  paper  so  closely  corroljorates  my  own 
experience  with  the  operation  that  I  venture  to  introduce  herewith  the  closing 
pages  of  it: 

"In  the  First  Ch-necological  Service  at  ^Nlount  Sinai  Ho.'-pital,  this  operation, 
with  some  modifications,  has  been  performed  one  hundred  and  six  times  in  the 
past  six  years.  The  modifications  have  consisted  of  four  factors.  The  principal 
one  has  been  the  omission  of  the  denudation  of  the  anterior  wall,  which  we 
have  not  considered  essential  to  the  proper  development  of  the  operation,  and 
which  Dudley  also  now  dispenses  with.  The  second  has  been  the  occasional, 
but  infrecjuent,  omission  of  the  excision  of  the  wedge-shaped  piece  of  the  pos- 
terior lip  of  the  cer^-ix.  The  third  consists  in  the  wide  dilatation  of  the  cervix, 
which  renders  the  operation  easier:  and  the  fourth  consists  in  using  clxromicized 
catgut  where  Dudley  employs  silkworm  gut  to  close  the  cervical  womid. 

"The  performance  cf  the  operation  is  exceedingly  simple,  and  offers  no  tech- 
nical difficulty.  We  have  found  it  of  advantage  both  as  to  speed  and  security 
to  have  the  suture  attached  to  a  needle  at  each  end,  and  to  .start  the  suture  at 
the  superior  or  anterior  portion  of  the  incision,  tving  it  in  the  posterior  fornix 
behind  the  cut  edge  of  the  cenix. 

"In  all  of  the  cases  the  operation  proper  has  been  preceded  by  a  thorough 
and  prolonged  dilatation  of  the  cer^■ical  canal  and  a  fight  curettage.  The 
cer^'ical  dilatation  is  a  ven,^  essential  feature,  inasmuch  as  it  permits  of  the 
easier  manipulation  of  the  posterior  lip  of  the  cervix  after  it  has  been  incised. 
We  have  often  found  it  necessary  also  to  figate  a  small  branch  of  the  circular 
artery  of  the  cervix,  which  is  cut  into  when  the  wedge-shaped  piece  of  the 
cervical  tissue  is  excised.  In  all  other  respects  we  have  followed  the  directions 
of  Dudley  as  given  in  his  original  article  and  in  his  book. 

"One  of  the  direct  results  of  this  operation  is  that  the  position  of  the  os 
externum  in  the  vagina  is  changed.  Instead  of  lying  against  the  anterior 
vaginal  wall,  if  the  uterus  is  in  sharp  anteflexion,  or  midway  between  the 
anterior  and  posterior  vaginal  waU,  if  the  uterus  is  moderately  anteflexed.  it 
now  points  toward  the  posterior  waU.  In  this  way  the  reception  of  the  semen 
into  the  uterus  is  verv-  much  fostered;  for.  as  many  ^Titers  have  pointed  out, 
if  the  cer^-ix  lies  again.st  the  anterior  wall,  access  of  the  semen  to  the  uterus 
is  practically  excluded. 

"Another  and  striking  result  is  the  change  which  takes  place  in  the  curve 
of  the  uterine  canal.  Whereas  before  operation  the  uterus  lay  in  very  marked 
anteflexion,  with  a  most  marked  curve,  as  soon  as  the  suturing  is  completed 
the  sound  will  be  foimd  to  follow  practically  a  straight  course  toward  the 
fundus.    It  is  easy  to  tmderstand  why  this  should  be  so,  for  the  entire  direc- 

1  SurgeiT}'.  Gynecologj-,  and  Obstetrics,  November,  1911 

43 


706  DISPLACEMENTS 

tion  of  the  lower  portion  of  the  uterus  is  changed,  the  cervix  pointing  directly 
backward. 

"It  matters  very  little  whether  Olshausen^  is  correct  in  his  belief  that  the 
external  os  plays  no  role  in  the  causation  of  dysmenorrhoea  and  that  the  blame 
must  be  put  entirely  on  the  internal  os,  or  whether  Jaquet^  is  right  in  the  dia- 
metrically opposite  faith.  In  the  operation  as  devised  by  Dudley  both  the 
external  and  the  internal  os  are  divided,  and  both  are  changed  in  direction  and 
in  becoming  more  patulous. 

"While  we  have  tried  other  measiu-es  for  the  relief  of  both  sterility  and 
dysmenorrhea,  this  report  will  deal  only  with  the  results  of  the  Dudley  opera- 
tion. 

"In  every  case  operated  upon  by  us  (Drs.  Brettauer,  Frank,  and  mj^self), 
selection  was  carefully  made.  Thus,  in  every  instance,  an  examination  of  the 
husband  was  made  to  preclude  the  possibility  of  his  being  responsible  for  the 
sterility.  Contraindications  were  carefully  stucUed  in  both  the  cases  of  sterihty 
and  dysmenorrhoea.  No  patient  was  subjected  to  the  operation,  who  had  ever 
had  inflammatory  pelvic  disease,  or  in  whom  there  was  any  gross  pathological 
condition  of  the  pelvis,  or  in  whom  there  was  diabetes,  nephritis,  tuberculosis, 
or  grave  cardiac  disease.  We  have  not  considered  a  contracted  pehas  as  a 
contraindication,  as  patients  -with  this  condition  can  be  properly  taken  care 
of  when  they  become  pregnant.  A  few  of  the  patients  had  small,  hj^poplastic 
uteri;  but  although  an  infantile  uterus  does  not  offer  a  promising  result,  it  was 
not  looked  at  as  a  contraindication  to  operation,  since  it  might  give  relief  to 
the  dysmenorrhoea  for  which  the  patient  came  to  the  hospital.  Many  of  the 
patients  suffered  from  a  non-specific  form  of  endocervicitis,  which  has  been 
recognized  by  Kelly'  as  a  source  of  dysmenorrhoea. 

"The  majority  of  patients  gave  microscopic  evidence  of  a  chronic  endo- 
metritis, although  very  few  complained  of  leucorrhoea. 

"  In  general  the  patients  presented  themselves  with  a  history  of  mere  sterility, 
dating  from  eight  months  to  twelve  years.  They  complained  of  nothing  else. 
In  our  ward  patients  this  is  a  serious  complication  of  married  hfe,  for  most  of 
them  are  Russians  or  Poles;  and  if  they  remain  barren,  they  are  eventually 
deserted  or  divorced^  by  their  brutish  husbands.  The  other  general  class  of 
patients  complained  only  of  dysmenorrhoea,  varjang  from  slight  pain  to  severe 
agony.  Many  of  the  marriecl  women  sought  relief  from  both  dysmenorrhoea 
and  ioarrenness. 

"The  usual  finding  was  a  small,  anteflexed  uterus  ^^ath  a  long,  conical  cervix. 
In  many  instances  the  external  os  could  not  be  passed  by  a  sound.  This  con- 
stituted, in  the  absence  of  the  contraindications  above  noted,  an  indication  for 
the  Dudley  operation. 

"I  have  recently  made  a  circular  inquiry  of  the  106  patients,  and  answers 
were  received  from  52  ward  patients  and  21  private  patients;  a  total  of  73. 
Thirty-three  letters  were  returned,  the  persons  not  being  found  by  the  post- 
office  department.  I  have  kept  the  reports  of  ward  and  private  patients 
separate,  for  the  private  patients  were  of  a  different  walk  in  life,  and  it  seemed 
interesting  to  compare  results.  The  following  tables  give  the  summary  of  the 
results  as  shown  in  the  replies  received,  not  all  of  the  patients  answering  all  the 
questions. 

1  Ueber  Amenorrhcsa  und  Dysmenorrhcea.     Zeitsch.  f.  Geburts.  u.  Gypak.,  1904,  li,  226. 

2  Ueber  die  Diszision  des  Muttermundes.     Zeitsch.  f.  Geburts.  u.  Gynak.,  1901,  xlvii,  144. 

3  Medical  Gynecologj'. 

*  Through  the  efforts  of  several  charitable  institutions,  the  divorces  or  desertions  of  women  of  this 
class  have  become  markedly  diminished  in  recent  years. 


ANTEVERSION  AM)  AXTEFLEXIOX  OF  THE   UTERUS       7()7 


TABLK   I 

"Wartl   patients,   52.     Twenty-nine   applierl   for   relief  of  dysmenorrhcea. 
and  29  for  dysmenorrhcea  and  sterility." 


D>'smen. 
Relieved. 

'            Dysmen. 
Not  relieved. 

Dysmen. 
Worse. 

1 

16 
5.Vl+% 

1                  12 

41.3+% 

1 
3+% 

Sterility 
Roiioved 

Sterility 
Not  relieved 

Instrumental 
dpliver>- 

Abortions. 

17.2+% 

'                   24 

83.8—% 

1 
20% 
(of  the  relieved 
cases) 

1 

fof  the  relieved 
cases; 

TABLE   II 

"Priyate  patients,  21.     Thirteen  applied  for  relief  of  dy.smeiiorrha'a,  and 
19  for  dysmenorrhcea  and  sterility. 


Dy.<5men. 
Relieved. 

Dysmen. 
Xot  relieved. 

'            Dysmen. 
Worse. 

11 

84.6% 

2 
15.4% 

0 

Sterility 
Relieved 

Sterility 
Xot  relieved 

;         Instrumental 
Deliveries 

Abortions 

8 
42.1% 

;                  11 
1               57.9% 

1               15.8% 

(of  the  relieved 
1                cases) 

0 

"The  percentages  are  ba.sed  upon  the  actual  answers  receiyed,  not  upon  the 
total  number  of  replies  receiyed.  At  a  glance  it  is  e^^dent  that  the  priyate 
patients  were  much  the  gainers  by  the  operation,  both  as  to  the  relief  of  the 
dysmenorrhcea  and  the  sterility.  It  is  difficult  to  account  for  this.  Possibly 
the  poorer  li^^ng  conditions,  so  far  as  food  and  rest  and  hard  work  are  con- 
cerned, play  some  role;  but  I  haye  no  more  definite  reason  to  offer  than  this, 
for  the  cases  were  .selected  with  equal  care. 

"Combining  the  figures  for  both  classes,  we  haye  this  table: 


TABLE  III 

"Patients,  73.     Forty-two  applied  for  relief  from  dysmenorrhcea,  and  48 
from  dysmenorrhcea  and  sterility." 


Dysmen. 
Relieved. 

Dysmen. 
Xot  relieved. 

Dysmen.             ' 
Worse. 

27 
64.3% 

14 
33.3+% 

1 

2.4% 

Sterilitv 
Relieved 

Sterility 
Xot  relieved 

Instrumental 
Delivers- 

Abortions 

13 
27% 

35 
73% 

4 

8+% 

1 
2+% 

708  DISPLACEMENTS 


TYPICAL  CASES 

"Case  1.  Dysmenorrhoea,  anteflexion,  long,  conical  cervix;  Dudley's 
operation.  Miss  E.  W.,  consulted  me  in  October,  1906.  She  is  a  college  student, 
aged  nineteen  years.  Her  menses  appeared  at  fourteen,  always  regular,  last- 
ing four  or  five  days,  not  profuse.  On  the  day  preceding  the  appearance  of 
her  menses  she  had  terrific  pains,  which  lasted  for  forty-eight  hours.  After  the 
expulsion  of  a  clot  at  this  time,  her  pain  diminished.  She  was  obliged  to  be 
in  bed  for  three  days.  Examination  showed  a  long,  thick,  conical  cervix,  with 
a  normal-sized,  sharply  anteflexed  uterus.  She  was  operated  at  Mount  Sinai 
Hospital,  December  1.5,  1906.  It  was  a  typical  Dudley  operation.  Recovery 
uneventful.  From  that  time  on  the  menses  have  been  practically  painless. 
The  patient  could  continue  her  studies  uninterruptedly,  and  was  never  obliged 
to  go  to  bed  during  her  period.  She  subsequently  married,  and  was  delivered 
bv  me  on  April  1,  1910,  by  low  forccDS.  •       t^    „     , 

'"Case  2.  Dysmenorrhoea,  retroflexion,  long,  conical  cervix;  Dudleys 
operation  and  ventral  fixation.  Miss  A.  M.  S.,  a  dancing  teacher  m  a  Western 
citv  consulted  me  July  1,  1901.  She  was  aged  thirty-five  years.  The  first 
menses  were  at  thirteen,  regular,  of  the  four-weekly  type,  lasting  five  to  six  days. 
She  had  no  pain  until  her  eighteenth  year.  Since  then  she  had  been  obliged  to 
remain  in  bed  for  three  days.  She  had  vomiting  and  intense  pain.  The  flow 
was  scant  at  first,  often  clotted,  and  there  was  a  feeUng  of  bearing  down.  There 
was  no  vaginal  discharge.  This  patient  had  had  local  treatment.  She  had 
worn  a  cervical  pessary,  had  had  electrical  treatment,  and  had  been  under 
Christian  Science  care."  The  examination  showed  an  easily  dilatable  hymen, 
a  long,  hard,  conical  cervix,  pointing  to  the  symphysis,  and  a  very  sharply 
retroflexed,  movable  uterus.  She  was  operated  at  Mount  Sinai  Hospital, 
.July  3,  1909.  It  was  a  typical  Dudley  operation  followed  by  ventral  fixation. 
Recovery  uneventful.  I  have  had  repeated  letters  from  this  patient,  the  last 
one  a  month  ago.  She  is  free  from  aU  pain,  conducts  large  private  classes  in 
dancing,  and  leads  the  children  of  her  city  in  folk  dances. 

"Case  3.  Sterility;  Dudley's  operation.  Mrs.  F.  W.  M.,  aged  thirty-seven 
years,  married  two  years,  never  pregnant.  She  was  first  seen  April  6,  1906. 
She  had  menses  since  the  fourteenth  year,  always  regular,  somewhat  painful 
on  the  first  day,  not  profuse.  She  was  very  anxious  to  have  a  child.  Examina- 
tion revealed  a  hymen  stretched  rather  than  torn,  with  a  very  small  opening. 
The  uterus  was  anteflexed,  with  a  long,  conical  cervix.  The  husband's  semen, 
examined  by  Dr.  F.  S.  Mandlebaum,  was  healthy.  The  patient  was  given 
advice  as  to  various  procedures  to  assist  her  in  becoming  pregnant,  but  these 
did  not  avail.  Operation  was  performed  at  her  home  on  May  12,  1906,  \\ath 
the  assistance  of  Drs.  R.  T.  Frank  and  Bennett,  by  excision  and  suture  of  the 
hymen,  and  typical  Dudley's  operation.  The  recovery  was  uneventful.  On 
May  29  the  cervix  pointed  downward  and  backward,  and  the  external  os  easily 
admitted  the  sound.  This  patient  went  abroad  the  following  month  and  con- 
ceived in  July,  1906,  being  delivered  by  me  in  May,  1907.  I  have  since  delivered 
her  again  in  1910.  In  this  case  there  can  be  no  doubt  that  the  pregnancy 
followed  as  a  direct  result  of  the  operation. 

"Case  4.  Sterility  and  dysmenorrhoea,  anteflexion,  stenosis  of  external 
os;  Dudley's  operation.  Mrs.  M.  E.  M.,  aged  twenty-six  years,  married  two 
years;  first  seen  September  20,  1904.  Has  never  been  pregnant.  First  menses 
appeared  at  fourteen  years,  regular,  every  twenty-seven  days,  lasting  about 
three  days.  The  first  day  was  spent  in  bed  on  account  of  great  pain  (cramps). 
Examination  showed  a  sharply  anteflexed  uterus  and  a  long,  conical  cervix. 
The  husband  had  had  gonorrhoea,  but  his  semen  contained  living  spermatozoa. 
She  was  operated  at  her  home  November  20,  1904,  with  the  assistance  of  Dr. 
W.  M.  Brickner.  It  was  a  typical  Dudley's  operation,  with  convalescence 
uneventful.     The  patient  became  pregnant  on  the  first  intercourse  following 


ANTEVERSION  AND  ANTEFLEXION  OF  THE   UTERUS       709 

the  operation,  one  month  later,  and  was  delivered  by  me  in  October,  1905, 
after  a  normal  labor.  She  is  again  pregnant  now.  This  is  a  case  in  which, 
after  two  years  of  married  life,  the  patient  failed  to  conceive  until  the  stenosis 
of  the  cervix  and  the  anteflexion  were  corrected  by  operation." 


THE  CERVIX  IX   LABOR,  AFTER  DUDLEY'S  OPERATION 

"I  have  delivered  seven  women  upon  whom  the  Dudley  operation  had  been 
performed  for  the  relief  of  dj'smenorrhoea  and  sterility.  In  not  one  of  them 
was  there  an^-thing  in  the  conduct  of  the  labor  out  of  the  ordinar^^  In  two 
of  them  a  low  forceps  operation  was  necessary,  but  as  far  as  dilatation  of  the 
cervix  was  concerned,  the  first  stage  in  all  was  absolutely  normal.  The  reason 
for  this  lies  undoubtedly  in  the  fact  that  the  wound  in  the  cervix  is  a  clean-cut 
one,  and  heals,  almost  without  exception,  primarily.  So  that  we  have  a  cervix 
even  niore  favorable  for  dilatation  during  labor  than  one  upon  which  a  trachel- 
orrhaphy has  been  performed,  since  we  have  no  scar  tissue  to  contend  with. 
I  have  watched  the  wounds  in  these  cervices  with  special  care  and  interest. 
In  a  few  months  the  posterior  lip  of  the  cer^-ix  feels  no  differently  than  the 
anterior  lip.  It  is  just  as  soft  and  smooth;  but  the  site  of  the  incision  can  be 
palpated  and  seen,  although  it  is  not  rough  and  hard.  As  far  as  the  conduct 
of  the  cervix  itseK  is  concerned,  then,  during  labor,  Dudle3^'s  operation  offers 
no  contraindication. 

"It  would  be  unfair  to  Dr.  Dudley  not  to  mention  the  fact  that  in  the  Zeit- 
schrift  fiir  Geburtshlilfe  mid  G^aiakologie,  1908,  Ixii,  465,  there  appears  an 
article  by  Dr.  Ludx^ig  Herzl,  from  the  clinic  of  Professor  G.  Lott  in  Vienna, 
entitled:  'Ueber  die  hintere  sagittale  Diszision  der  Cer\ix  uteri.'  In  this 
paper  the  author  descril^ed  posterior  sagittal  discission  or  incision  of  the  cervix 
as  practised  in  the  clinic  of  Professor  Lott.  Herzl  does  not  say  how  long  this 
method  has  been  practised  by  Professor  Lott,  nor  when  he  began  to  use  it. 
This  is  unfair  and  unprofessional  and  unethical;  and  I  wish  emphatically 
to  protest  against  it,  and  to  say  that  this  particular  operation  belongs  to  the 
credit  of  Dudley,  of  Chicago.  Nowhere  in  the  literature  is  there  a  description 
of  any  similar  procedure  except  in  the  paper  I  have  mentioned;  and  this  was 
printed  in  1908,  while  Dudley  described  his  operation  in  1891. 


SUMMARY 

"1.  Dudley's  operation  of  posterior  sagittal  incision  of  the  cer\nx  with  or 
without  the  excision  of  a  bilateral  wedge,  for  the  relief  of  dysmenorrhcea  and 
sterility,  is  a  procedure  to  be  recommended. 

"2.  It  is  of  greater  service  in  the  relief  of  dysmenorrhoea  than  of  steriUty, 
although  in  the  latter  the  effect  is  sometimes  magical. 

"3.  The  resulting  scar  in  the  cervix  offers  no  hindrance  to  labor,  dilatation 
being  as  normal  as  possible. 

"■4.  Pathological  anteflexion,  or  retroflexion  of  a  hypoplastic  uterus,  with 
stenosis  of  the  external  or  internal  os,  or  of  both,  is  a  frequent  cause  of  sterihty 
and  of  dysmenorrhoea. 

"  5.  These  conditions  can  be  reUeved  in  about  50  per  cent,  of  properly  selected 
cases  by  Dudley's  operation;  but  no  operation  for  sterility  should  be  performed 
until  the  husband  is  found  to  possess  living  spermatozoa;  and  no  operation 
should  be  performed  for  dysmenorrhoea  mthout  a  thorough  study  of  all  the 
features  of  the  case,  for  there  are  cases  which  yield  to  no  form  of  operation." 


710  DISPLACEMENTS 

TORSION  OF  THE  UTERUS 

Any  part  or  the  whole  of  the  uterus  may  turn  on  its  own  axis— 
that  is,  be  twisted  upon  itself. 

Causes  of  Torsion  of  the  Uterus 

The  causes  of  this  displacement  are: 

1.  Anteflexion    associated    with    contraction    of    one    uterosacral 

ligament. 

2.  Retroflexion. 

3.  Uterine  tumors. 

4.  Tumors  of  the  uterine  appendages. 

5.  Double  uterus;  one  horn  may  lie  anterior  to  the  other. 

Diagnosis  and  Treatment  of  Torsion  of  the  Uterus 

Torsion  of  the  uterus  may  be  recognized  by  conjoined  examination 
which  will  demonstrate  the  anterior  surface  of  the  uterus  lying,  not 
directly  in  front,  but  to  one  side.  The  long  axis  of  the  uterus  generally 
is  found,  not  in  the  median  line,  but  having  a  diagonal  direction  across 
the  pelvis.    The  treatment  is  that  of  the  causative  complications. 


CHAPTER   XLIII 

INVERSION  OF  THE  UTERUS— HERNIA  OF  THE  UTERUS 

AND  OVAliY 

INVERSION   OF   THE  UTERUS 

Inversion  of  the  uterus  is  the  partial  or  complete  turning  of  the 
organ  inside  out.  The  difference  between  partial  and  complete  inver- 
sion is  simply  one  of  degree.  In  partial  inversion  some  part  of  the 
wall  of  the  corpus  uteri,  usually  the  fundus,  is  depressed  into  the  uterine 
cavity,  but  the  organ  does  not  protrude  through  the  external  os  into 
the  vagina.  In  complete  inversion  the  uterus  has  turned  completely 
inside  out.  The  inverted  uterus  is  then  inside  the  vagina,  or,  if  the 
vagina  is  also  inverted,  both  organs  will  be,  to  quote  Hippocrates, 
between  the  thighs,  "  velut  scrotum."^  Figures  416  to  425  represent  the 
incomplete  and  complete  forms  of  in^•ersion. 

Etiology  of  Inversion  of  the  Uterus 

More  than  10  per  cent,  of  all  cases  are  puerperal.  The  causes  usually 
assigned  are  traction  on  the  cord  in  the  delivery  of  the  placenta,  traction 
in  the  rapid  delivery  of  the  child,  traction  by  gravity  of  intra-uterine 
tumors,  or  traction  exerted  in  their  delivery.  These  causes,  however, 
are  all  inadequate  to  produce  the  accident  unless  the  muscular  walls 
of  the  uterus  are  predisposed  by  relaxation.  Paralysis  or  great  relaxa- 
tion of  the  uterine  wall  is  the  essential  cause  of  the  accident.  Undue 
importance  has  been  given  to  the  various  forms  of  traction;  even 
coughing  or  sneezing  may  mvert  a  very  relaxed  uterus.^ 

Inversion  in  the  majority  of  cases  occurs  spontaneously  as  a  direct 
result  of  paralysis  of  uterine  muscles.  This  paralysis  may  pertain  to  any 
part  or  all  of  the  uterine  wall,  but  is  usually  most  pronounced  at  the 
placental  site.  The  paralyzed  portion  is  depressed  first  into  the  uterine 
cavity,  so  as  to  give  the  corpus  uteri  the  appearance  of  the  bottom 
of  a  junk  bottle.  The  uninverted  portion  of  the  muscular  wall,  not 
being  paralyzed,  may  contract  and  seize  the  partially  inverted  paralyzed 
portion,  and  push  it  down  farther  and  farther  until  inversion  is  complete. 

The  conditions  that  most  favor  paralysis  and  relaxation  of  the  mus- 
cular layers  are  not  wholly  known.  The  accident  in  about  SS  per  cent, 
of  all  cases  is  associated  with  childbirth;^  hence  the  inference  that  the 


1  Hippocrates.      From  Thomas  and  Mund6. 

2  Adaptation  from  Thomas  and  Mund§.      Diseases  of  Women. 
'  Crosse.     Loc.  eit. 


(711 


712 


DISPLACEMENTS 


most  active  causes  are  connected  with  uterogestation  and  parturition. 
In  a  small  proportion  of  cases  inversion  has  followed  distension  of  the 


Figure  416 


Acute  case,  uterus  inverted  completely  into  vagina:  0  0,  ovaries;  T  T,  FaUopian  tubes;  P, 
placenta  still  attached  to  uterus.  Openings  of  Fallopian  tubes  through  inverted  fundus  are 
shown  in   section. 


endometrium  by  retained  fluids  or  tumors.     The  hemorrhage,  often 
associated  with  muscular  relaxation  of  the  uterus,  is  not  a  cause,  but  a 


INVERSION  OF  THE  UTERUS 


713 


Figure  418 


Figure  419 


FiorRE  417. — Partial  iiiver.<i;>i  of  the  loft  horn  of  the  uterus. 

FuifRE  41S. — Myoma  siinulatinz  partial  inversion  at  the  left  horn  of  the  uterus. 

Figure  419. — Partial  inversion  of  the  uterus  comphcated  by  and  caused  by  a  myoma. 


FicuRE  420 


Figure  421 


Figure  422 


Figure  420. — Partial  inversion  of  the  uterus;  the  fundus  is  at  the  os  externum. 

Figure  421. — Pedunculated  myoma  protruding  from  the  os  externum,  resembling  an  inverted 
fundus  uteri. 

Figure  422. — Slight  inversion  of  the  fundus  uteri  ^s-ith  pedunculated  uterine  myoma  protruding 
through  the  os  externum  and  resembhng  inversion. 


Figure  423 


Figure  424 


Figure  42.5 


Figure  423. — Complete  inversion  of  the  uterus  complicated  by  a  myoma  in  the  peritoneal  cavity, 
which  has  all  the  physical  appearance  of  a  uterus.  There  is  difficulty  in  such  a  case  in  determining 
which  is  the  uterus  and  which  is  the  myoma. 

Figure  424. — The  uterus  is  inverted  completely  into  the  vagina. 

Figure  425. — The  reverse  of  Figure  423. 


714  DISPLACEMENTS 

result  of  the  relaxation.  Finally,  we  may  say  that  the  condition  in  a 
large  proportion  of  cases  arises  without  definite  assignable  cause.  The 
accident  occurred  at  the  Rotunda  Hospital  but  once  in  190,800,  and 
at  the  Vienna  Lying-in  Hospital  but  once  in  250,000  deliveries.^ 

A  most  instructive  case  has  been  recorded  by  Willard  Parker,  as 
follows : 

"A  young  woman,  who  had  borne  one  child  seven  or  eight  years 
previously,  and  had  never  had  any  recognized  uterine  disease,  while 
making  a  violent  effort  in  rolling  tenpins  suddenly  felt  something 
give  way  within  her,  after  which  she  suffered  the  most  intense  pain 
and  became  completely  disabled.  Dr.  Parker,  being  called  to  see  her, 
after  a  hasty  examination  coincided  with  the  opinion  of  the  attending 
physician,  that  a  polypus  had  been  suddenly  expelled  and  was  hanging 
in  the  vagina.  Impressed  with  this  belief,  he  removed  the  whole 
mass,  when,  to  his  surprise,  he  found  in  his  hands  the  inverted  uterus 
with  its  tubes  and  ligaments.  The  patient  recovered  without  any  bad 
symptoms,  and  subsequently  menstruated  regularly. "^ 

The  occasional  occurrence  of  spontaneous  replacement  of  a  uterus 
that  had  been  inverted  has  been  observed  repeatedly,  and  is  a  fact  no 
less  remarkable  than  spontaneous  inversion.  In  one  case  replacement 
occurred  while  the  patient  was  straining  at  stool  .^ 

Mechanism  of  Inversion  of  the  Uterus 

If  the  entire  uterine  walls  are  paralyzed,  the  organ  may  invert  as 
the  result  of  traction  or  coughing  or  sneezing,  or  of  its  own  weight. 
Intra-abdominal  force  from  above  may  push  the  paralyzed  uterine 
wall  through  the  os  externum  into  the  vagina.  If  the  paralysis  per- 
tains to  only  a  part  of  the  uterine  wall,  the  inversion,  as  already  ex- 
plained, may  occur  by  contraction  of  the  non-paralyzed  portion.  Clearly 
inversion  cannot  take  place  when  the  entire  uterine  wall  is  active. 
It  may,  however,  do  so  when  the  paralysis  is  partial  and  the  activity 
is  partial.  Regional  paralysis,  as  already  stated,  is  more  apt  to  occur 
at  the  placental  site,  where  the  wall  is  thinner  and  softer.  It  more 
frequently  occurs  at  the  fundus  or  at  one  of  the  horns. 

In  some  cases  the  inversion  takes  place  from  below  upward — that 
is,  the  relaxed  cervical  portion  comes  down  as  in  prolapse  of  the  anus. 
This  process  begins  as  eversion,  and  continues  until  the  whole  organ 
is  inverted. 

Anatomy  and  Pathology  of  Inversion  of  the  Uterus 

The  inversion,  if  not  complete,  may  have  been  arrested  at  any  point. 
Thus  the  inverted  portion  may  be  above  the  internal  or  external  os; 
or  it  may  consist  of  the  entire  uterus  rolled  out  into  the  vagina; 
or,  together  with  the  inverted  vagina,  the   inverted   uterus  may  be 

1  Playfair  and  AUbutt.     System  of  Gynecology. 

2  Thomas  and  Mund6.     Diseases  of  Women.  ^  Thomas.     Diseases  of  Women. 


INVERSION  OF  THE   CTERUS  715 

outside  of  the  vulva.  The  exposed  uterine  mucosa  is  then  dark  red 
or  purple  from  e()u<;'esti()n,  and  there  may  l)e  rejj^ional  ecchymosis, 
erosion,  and  ulceration.  Adhesions  luue  been  known  to  form  between 
the  wholly  extrudetl  uterus  and  the  vajijina.  The  writer  has  observed 
one  case  in  which  such  adhesions  had  formed  l)etween  the  partially 
inverted  corpus  and  the  cervical  mucosa. 

There  is  hemorrha.y;e  from  the  extruded  and  inflamed  uterine  mucosa. 
In  the  combined  inversion  of  the  uterus  and  ^•agina  the  muco.sa,  after 
long  exposure  to  external  influences,  may  become  dry,  wrinkled,  and 
parchment-like,  as  does  the  vagina  in  comi)lete  procidentia  of  the 
unin\erted  uterus;  the  two  conditions  have  been  mistaken  for  one 
another. 

The  vessels  are  strangulated,  circulation  is  impeded,  the  nutrition 
of  the  organ  suffers,  and  some  degree  of  infection  is  almost  inevitable. 
In  rare  instances  gangrene  and  sloughing  of  the  inverted  portion  have 
taken  place. 

The  uterine  ligaments,  Fallopian  tubes,  ovaries,  and  even  intestine 
may  at  first  be  drawn  into  the  peritoneal  cup  of  the  inverted  organ. 
Rarely  these  organs  become  adherent  within  the  cup;  usually  with 
returning  uterine  activity  and  contraction  they  are  expelled  and 
remain  outside. 


Symptoms  of  Inversion  of  the  Uterus 

The  sjTiiptoms  of  acute  complete  inversion  of  sudden  occurrence 
are  as  follows: 

Fixed  intense  pain. 
Profuse  hemorrhage. 
Shock  and  collapse. 
Partial  inversion  may  occur  with  no  characteristic  symptoms,  and, 
v.ithout  physical  examination,  may  escape  notice. 

Chronic  inversion  may  have  dcAcloped  slowly,  or  may  follow  acute 
inversion;  it  causes: 

IMechanical  disorders  of  the  urinary  organs  and  rectum. 
Hemorrhage,  more  or  less  profuse,  and  consequent  anaemia. 
Bloody,   purulent,   or   serous   discharges. 
Difficulty  in  walking  and  standing. 
Pehac  pain. 
Nerve   exhaustion    and    impaired    health    necessarily   follow.      Life 
may  be  destroyed  slowly  by  the  exhaustive  drain,  or  at  any  time 
rapidly  by  acute  peritonitis.     In  rare  instances,  especially  after  the 
menopause,  there  may  be  only  slight  inconvenience  or  none  at  all. 


Diagnosis  of  Inversion  of  the  Uterus 

If  the  abdominal  walls  are  relaxed  and  thin,  and  permit  adequate 
palpation  of  all  the  intrapelvic  organs,  conjoined  examination  will 


716  DISPLACEMENTS 

show:  first,  the  absence  of  a  part  or  a  whole  of  the  uterus  in  the  place 
where  it  normally  belongs;  and,  second,  its  presence  inverted  partially 
or  wholly  in  the  vagina  or  in  the  uterine  canal.  The  concavity  or 
peritoneal  depression  caused  by  the  inversion  sometimes  may  be  felt 
through  the  abdominal  wall.  Rectal  touch  or  combined  rectal  and 
vaginal  touch,  with  the  hand  over  the  abdomen  or  the  sound  in  the 
bladder,  may  facilitate  the  diagnosis.  The  finger  in  the  rectum  may 
be  made  to  meet  the  hand  over  the  abdomen  or  the  sound  in  the 
bladder,  and  thereby  demonstrate  the  absence  of  a  uterus  above  the 
vagina.  The  orifices  of  the  Fallopian  tubes,  now  rolled  out  and  ex- 
posed, also  may  be  demonstrable.  In  case  of  rigid  thick  abdominal 
walls  the  diagnosis  will  be  more  difficult. 

The  differential  diagnosis,  in -a  given  case,  may  raise  two  questions: 
First,  Is  the  protruding  mass  a  uterine  myoma  or  polypus,  or  a  vaginal 
tumor?    Second,  Is  it  a  prolapsed  uterus? 

Is  it  complete  inversion?  Is  it  myoma  or  polypus? 

1.  No  pedunculated  attachment  to  uterus.  1.  Attached  to  the  uterine  wall  by  broad  sur- 

face or  by  narrow  pedicle. 

2.  Uterine  cavity  being  obliterated,  sound  can  |       2.   Sound    passes    by    the    side    of    the    mass 
be  passed  but  short  distance  in  incomplete  and      through  external  os  far  into  the  uterine  cavity. 
not  at  all  in  complete  inversion. 

3.  Vaginal    or    rectal    conjoined    examination   ,        3.   Uterus  felt  above  vagina. 
shows    a   ring    or    depression    where    the   uterus 

should  be,  and  fails  to  show  the  uterus  above  |  - 

the  vagina. 

4.  The  inverted  uterus  is  a  symmetrical  pyri- 
form  body. 

5.  Orifices    of    the    Fallopian    tubes    usually 
demonstrable. 

6.  Muciparous   glands    of   the    uterus   present 
and  microscopically  demonstrable. 


Is  it  incomplete  inversion  of  the  uterus? 


4.  Not  usually  symmetrical  and  may  be  very 
asymmetrical. 

5.  Not  present. 

6.  Not   present,    or    if   present    less    perfectly 
developed. 


7s  it  an  intra-uterine  myoma? 


1.  The    uterine    cavity     as    measured    by    the  1.  Cavity  enlarged, 
sound  will  be  diminished. 

2.  Development  usually  sudden.  '       2.  Development  gradual. 

3.  Bimanual  examination   shows  ring-like   de-  3.   Uterus   symmetrical    or   £.symmetrical,   but 
pression  in  wall  of  uterus.                                                  no  ring-hke  depression. 

4.  Usually  dates  from  parturition.  I       4.   No  parturition. 

The  great  difficulty  in  some  cases  of  making  the  differential  diag- 
nosis between  a  polypus  or  myoma  and  an  inverted  uterus  is  empha- 
sized by  the  fact  that  deservedly  eminent  surgeons  have  extirpated 
the  partially  or  wholly  inverted  uterus,  repeatedly,  under  the  mistaken 
diagnosis  of  a  myoma.  Conversely,  the  effort  has  been  made  to  reduce 
a  supposedly  inverted  uterus  when  the  extruding  mass  was  a  myoma. 
The  author  personally  recalls  a  case  at  the  Woman's  Hospital  in  the 
citv  of  New  York,  upon  which  such  an  attempt  was  made  persistently 
by  T.  G.  Thomas. 

In  rare  cases  the  diagnosis  has  been  obscured  by  the  presence  of  an 
inverted  uterus  in  the  vagina,  and  by  the  coexistence  of  a  subperi- 
toneal myoma  of  the  size,  shape,  consistence,  and  position  of  a  normal 
uterus.  The  distinction  between  the  two  bodies  might  then  depend 
solely  upon  the  presence  or  absence  of  the  orifices  of  the  Fallopian 
tubes  in  the  vaginal  mass.  Ordinary  care  and  intelligence,  however, 
usually  will  enable  the  surgeon  to  avoid  serious  mistakes.     Velpeau, 


INVERSION  OF  THE   f'TERUS  717 

quoted   by   Simpson,  once   sagely   remarked,  however,  that  in    some 
cases  doubt  is  the  only  rational  opinion. 

The  differential  diagnosis  between  inversion  and  procidentia  uteri 
usually  will  be  easy. 

Is  it  inversio  uteri?  /s  it  complete  procidentia  uteri f 

1.  The  protruding  mass  is  wider  below  than  1.  Mass  wider  above, 
above. 

2.  FC.\tcrnal  os  uteri  absent  and  tubal  orifices  2.  External  os  present  and  tubal  openings 
present  at  lower  end  of  mass.  absent. 

3.  Sound  in  urethra  goes  upward  into  bladder  3.  Sound  goes  downward  into  bladder,  but 
away  from  mass.  also  into  anterior  portion  of  mass. 

Exception. — When   the  vagina   is  concurrently 
inverted  the  sound  may  pass  downward. 

4.  Obliteration  of  vaginal  fornices.  4.   Obliteration  of  vaginal  fornices. 

5.  Finger    in    section    may    find    cup-shaped  5.  Not  so. 
"fundus." 

In  the  diagnosis  and  differential  diagnosis,  inspection  and  conjoined 
examination  and  the  sound  furnish  the  most  reliable  information. 

Prognosis  of  Inversion  of  the  Uterus 

If  replacement  can  be  effected  promptly  in  the  acute  stage  just 
after  the  occurrence  of  the  accident,  the  prognosis  is  immediately 
good.  If  replacement  be  delayed  until  rigid  contraction  renders  it 
more  difficult,  the  prognosis  will  be  correspondingly  more  serious.  The 
possible  dangers  arising  from  acute  inversion  are  from  hemorrhage, 
shock,  collapse,  and  acute  infection. 

Chronic  inversion,  unless  relieved  by  replacement,  is  likely  to  destroy 
health — if  not,  indeed,  life — by  slow,  exhaustive  hemorrhages,  uterine 
di.scharges,  and  consequent  ansemia.  Nervous  exhaustion  from  sur- 
gical efforts  to  replace  the  organ,  and  the  possibility  of  its  removal  by 
mistake  for  a  myoma,  are  positive  sources  of  danger.  Acute  infection 
and  peritonitis  are  among  the  always  dreaded  possibilities.  Few 
authentic  cases  of  spontaneous  reposition  have  been  recorded. 

In  rare  instances  the  inverted  uterus  gives  little  or  no  trouble,  even 
when  associated  with  complete  vaginal  inversion;  the  uterine  and 
vaginal  mucosa  possibly  may  undergo  changes  to  make  them  resemble 
skin,  the  surfaces  becoming  hard,  tough,  parchment-like,  and  wrinkled. 
Finally,  hemorrhages  may  cease,  and  the  woman  may  live  to  old  age 
in  comparati^'e  comfort. 

Treatment  of  Acute  Inversion  of  the  Uterus 

Puerperal  inversion  usually  takes  place  in  the  presence  of  the  attend- 
ant between  the  birth  of  the  child  and  the  delivery  of  the  placenta, 
and  may,  therefore,  in  the  acute  stage  be  recognized  while  uterine 
walls  still  are  relaxed  sufficiently  to  permit  immediate  replacement. 

If  the  placenta  still  is  attached,  it  should  be  removed  rapidly.  Under 
ansesthe-sia  the  hand  then  is  introduced  into  the  vagina  and  the  fundus 
pushed  up  through  the  cervical  canal  into  place.  Strong  contractions, 
with  alternating  relaxations,  are  usual  in  this  stage.     Reduction  by 


718  DISPLACEMENTS 

taxis  is  almost  impossible  during  the  contractions.  Instead,  therefore, 
of  handling  or  kneading  the  organ  to  reduce  its  size  by  contraction, 
the  attendant  waits  patiently  for  relaxation,  and  then  makes  a  steady, 
firm,  and  prompt  effort  at  replacement.  The  whole  corpus  may  be 
carried  up  at  once  or  it  may  be  necessary  with  the  finger-tips  to  indent 
the  fundus  at  some  point,  preferably  one  of  the  cornua,  and  let  this  be 
the  starting-point  of  the  replacement. 

Hot  water  and  a  fountain  syringe,  or,  better,  a  Davidson  syringe  of 
interrupted  current,  should  be  ready,  in  order  that  while  the  hand  is 
still  in  the  uterine  cavity  a  hot  douche  may  be  thrown  rapidly  into  the 
uterus.  The  hot  water,  by  its  stimulating  effect,  sets  up  strong  uniform 
uterine  contraction;  this  controls  hemorrhage  and  prevents  recurrence 
of  inversion.  The  hot  water  uterine  douche  in  the  control  of  post- 
partum hemorrhage  acts  in  the  same  way.  Within  a  few  hours  after 
the  accident  firm  uterine  contraction  or  retraction  takes  pices  in  the 
muscular  walls  of  the  inverted  uterus.  When  such  retraction  once 
is  established,  replacement  usually  will  be  quite  as  difficult  as  if  the 
condition  had  existed  for  months — that  is,  the  change  from  acute 
to  chronic  inversion  is  rapid. 

Treatment  of  Chronic  Inversion  of  the  Uterus 

Until  a  comparatively  recent  time  the  inverted  uterus,  once  con- 
tracted, was  regarded  incurable  except  by  hysterectomy.  On  the 
possibility  of  replacing  an  inverted  uterus  after  the  organ  had  con- 
tracted, the  late  Charles  D.  Meigs,  of  Philadelphia,  in  his  letters  to 
the  students  of  his  class,  in  1846,  wrote:  "You  might  as  well  attempt 
to  invert  one  of  the  non-gravid  uteri  on  my  lecture-table  as  to  reposit 
this  one.    The  time  for  replacement  has  gone  by."'^ 

The  Obstacles  to  Reposition  are  these: 

1.  Great  rigidity  in  the  contracted  cervical  ring. 

2.  Increase  in  the  volume  of  the  corpus  uteri  from  congestion. 
This  occurs  soon  after  inversion. 

3.  Later  increased  firmness  and  hardness  in  the  uterine  structures 
from  involution. 

4.  The  mobility  of  the  organ  and  the  difficulty  of  opposing  above 
sufficient  counterpressure  to  the  force  applied  below  in  the  effort  to 
replace. 

5.  Adhesions,  rare  but  possible,  between  the  sides  of  the  peritoneal 
cup. 

Methods  of  Reposition. — The  difficulty  of  overcoming  the  obstacles 
outlined  above  is  apparent  from  the  manifold  methods  that  have  been 
practised  by  different  surgeons.  The  lessons  to  be  learned  from  the 
combined  experience  of  these  methods  is  that  success  is  attained  best 
by  firm,  steady,  continuous,  elastic  pressure,  and  that  it  may  depend 
finally  upon  very  prolonged  and  patient  effort. 

1  Emmet.     Principles  and  Practice  of  Gynecology. 


IXVERSIOX  OF   THE   UTERUS 


19 


The  ohjoc-t  is  to  oxercoiiR'  tlie  riffidity  in  the  cervical  ring.  The 
])ressure  to  acconi])iish  this  may  l)e  uiiyieldiiij;  or  ehtstie.  Tlie  treat- 
ment ineliules  the  t'oiluwing  possible  procedures: 


Figure  426 


Manual  reposition  of  an  inverted  uterus. 


1.  Replacement  by  the  unaided  hands. 

2.  Replacement  by  the  hands  aided  by  incisions  or  instruments. 

3.  Continued  elastic  pressure. 

4.  Incision. 


720 


DISPLACEMENTS 


If  one  method  fails,  a  combination  of  two  or  more  methods  may- 
succeed. 

Preparatory  Treatment. — It  is  always  possible  in  the  course  of  an 
attempt  at  reposition  that  emergenices  may  arise  that  will  necessitate 
abdominal  or  vaginal  section;  hence,  the  necessity  of  making  prepara- 
tion for  those  operations.  See  Chapter  II.  In  addition  to  the  above, 
iron  may  be  required  for  anaemia,  and  hot  water  or  aseptic  gauze  tam- 
ponade in  the  vagina  may  be  needed  for  hemorrhage.  In  a  very  ansemic 
case  several  weeks  or  even  months  of  recuperative  treatment  may  be 
essential. 

Figure  427 


Reposition  of  the  mverted  uterus  by  the  method  of  J.  H.  Tate.  The  left  index  finger  is  in  the  bladder 
having  besa  passed  from  the  vajma  to  the  bladder  through  a  vesicovaginal  fistula  made  for  the  purpose. 
The  right  index  finger  is  i.i  the  rectum. 

Reposition  with  the  Hands,  Emmet's  Method.^ — The  patient, 
anaesthetized,  is  in  the  lithotomy  position.  The  left  hand  is  passed 
into  the  vagina,  the  fingers  and  thumb  are  forced  as  far  as  possible 
into  the  angle  of  reflexion,  so  as  to  encircle  the  part  of  the  corpus  uteri 
that  is  close  to  the  constricted  cervical  ring.  The  fundus  is  in  contact 
with  the  palm  of  the  hand,  and  is  pressed  firmly  upward  by  it,  while 
the  fingers  are  separated  to  their  utmost  to  open  the  cervix.  At  the 
same  time  the  right  hand  behind  the  pubes  slides  the  abdominal  wall 
back  and  forth  over  the  peritoneal  depression.  This  effort,  the  object 
of  which  is  to  open  out  the  contracted  ring,  is  put  forth  continuously. 
Finally,  the  rigid  cervix  uteri  may  begin  to  dilate,  the  corpus  may 
grow  shorter,  and  the  extent  of  inversion  may  lessen  proportionately. 


1  Loc.  cit. 


IXVERSION  OF   THE  UTERUS  721 

After  the  corpus  has  lieen  forced  partially  within  the  cervix  by  steady 
upward  i)ressure,  the  ti])s  of  the  Hnt^ers  are  brou^dit  toj^ether  as  a  wedge, 
passed  through  the  os,  and  made  to  complete  the  reposition. 

Emmet's  method  is  much  facilitated  by  keeping,  for  a  few  days 
previous  to  replacement,  a  widely  distended  Barnes  elastic  bag  in  the 
\agina.  The  bag  is  secured  firmly  by  a  T-l)andage.  This  dilates  the 
\agina,  makes  room  for  the  hand,  and,  by  the  elastic  upward  pressure 
which  it  exerts,  may  dilate  the  constricted  ring  or  even  by  itself  effect 
replacement.  In  one  case  complete  reposition  was  made  by  Emmet's 
method  in  three  hours  and  fifty-five  minutes. 

Emmet  further  suggests  in  case  of  partial  reposition,  when  the  cor- 
pus uteri  has  been  passed  inside  the  external  os,  that  the  progress  thus 
made  be  secured  by  temporary  closure  of  the  external  os  with  sutures. 

Tate's  Method  of  Taxis.' — The  index-  and  middle  fingers  of  the  right 
hand  are  passed  intcj  the  rectum,  and  the  index-finger  of  the  left  hand 
into  the  bladder  through  the  dilated  urethra.  The  balls  of  the  thumbs 
make  constant  firm  pressure  over  the  fundus,  while  the  fingers  in  the 
rectum  and  bladder  make  counterpressure  against  the  cervix.  In  this 
way  great  force  is  applied  more  directly  to  the  constricted  ring  than  by 
any  other  method.  In  a  case  of  forty  years'  standing  reported  by  Tate, 
the  thumbs  soon  indented  the  fundus,  the  cervix  began  to  dilate,  the 
corpus  was  pushed  through  the  cervix,  and  reduction  was  accomplished 
in  a  few  minutes.  Were  it  not  for  the  danger  of  rupture  of  the  urethra 
and  consequent  permanent  incontinence  of  urine,  this  method  would, 
perhaps,  have  the  preference  over  all  others.  Every  serious  objection 
could,  however,  be  overcome  by  opening  the  vesicovaginal  septum  and 
passing  the  finger  through  the  artificial  vesicovaginal  fistula  thus  made, 
instead  of  the  urethra.  The  fistula,  after  reposition,  could  be  closed  with 
little  difficulty  or  loss  of  time,  and  with  practically  no  additional 
danger.- 

There  are  numerous  other  methods  of  reduction  by  taxis,  but  they 
involve  no  valuable  principle  not  included  in  those  already  mentioned. 

Elastic  Pressure  by  the  Water-bag  or  Colpeurynter  has  been  mentioned 
in  the  preparation  for  Emmet's  method.  It  is  called  colpeurysis. 
Figure  428.  Reposition  may  be  begun  by  depressing  with  the  fingers 
one  horn  of  the  uterus,  and  the  depressed  portion,  if  forced  onward, 
serves  as  a  wedge  to  dilate  the  contracted  cervix.  The  hand  after  a  time 
becomes  fatigued  and  useless.  Colpeurysis  then  may  be  substituted  and 
long-sustained  elastic  pressure,  interrupted  occasionally  by  attempts 
at  manual  replacement,  may  be  effective.  In  many  cases  elastic  pres- 
sure alone  will  suffice.  There  is,  however,  no  short  limit  to  the  time 
during  which  it  may  be  necessary  to  continue  it.  In  some  cases  reposition 
finally  has  been  made  only  after  two  or  three  weeks  of  constant  effort, 
the  rubber  bag  filled  with  water  being  held  constantly  in  place  against 
the  inverted  fundus  uteri  by  means  of  a  tight  bandage,  so  that  it  vnll 
exert  constant  pressure. 

1  J.  H.  Tate.     Cincinnati  Lancet  and  Observ^er,  March,  1878.     Emmet- 
-  Suggested  by  Emmet.     Principles  and  Practice  of  Gynecology. 

44 


722 


DISPLACEMENTS 


An  effective  mode  of  using  elastic  pressure  is  that  described  by 
Thomas  and  Munde.^  Through  a  Sims  speculum  place  a  tampon  of 
aseptic  gauze  soaked  with  glycerin  firmly  around  the  cervix.  This 
keeps  the  uterus  from  slipping  out  of  the  line  of  pressure.  Shave  the 
pubes.     Introduce  a  large  rubber  bag  into  the  vagina  and  fill  it  with 


Figure  428 


\  '      i 


The  colpeurynter. 

water.  Cut  a  strip  of  adhesive  plaster  two  and  a  half  inches  wide, 
long  enough  to  reach  from  the  lumbar  region,  between  the  thighs,  over 
the  pubes  up  to  the  navel.  There  are  two  openings  in  the  plaster,  one 
for  transmission  of  the  tube  of  the  rubber  bag  and  one  for  the  urethra. 
The  plaster  is  cut  in  two  just  over  the  vulva,  and  that  portion  from  the 
vulva  to  the  anus  lined  with  a  layer  of  gauze.  The  two  parts  of  the 
plaster  are  held  together  by  three  safety-pins,  and  may  be  opened 


1  Diseases  of  Women,  p.  454, 


INVERSION  OF  THE  UTERUS  723 

diirin":  defecation  or  urination;  the  urine  if  necessary  is  drawn  by  a 
catheter.  The  ])ressure  may  be  increased  !)>■  ti^litenin<]j  the  plaster  or 
pumping  in  more  water;  it  may  be  decreased  by  K)oseninif  tlie  phister  or 
drawing  out  water  through  the  stop-cock  on  the  tube.  The  patient  is 
kept  in  bed,  and  pain  is  controlled  by  opium  or  morphine. 

Continued  elastic  i)ressure  by  colpeurysis  is  sometimes  not  tolerated, 
or  it  may  be  contraindicated  by  the  presence  of  inflammation.  Then 
annesthesia  and  more  energetic  measures  may  be  indicated.  Indeed, 
anti'Septic  surgery  as  now  practised  is  undoubtedly  much  safer  as  icell  as 
more  effective  than  prolonged  elastic  pressure  or  violent  taxis. 

Incision. — When  the  various  forms  of  taxis,  supplemented  by  gradual 
or  rapid  elastic  pressure,  fail,  the  rigidity  of  the  cervix  may  be  over- 
come by  incision.  This  plan  was  suggested  by  the  fact  that,  after 
forcible  dilatation,  the  cervix  was  usually  more  or  less  torn,  and  that 
an  incision  would  be  preferable  to  a  tear.  One  may  draw  down  the 
corpus  and  cut  nearly  or  quite  through  the  constricted  cer\ical  wall 
at  one  or  more  points,  and  then  reduce  the  inversion  by  taxis  or  rapid 
elastic  pressure;  or  incisions  may  be  made,  one  in  the  anterior  and  one 
in  the  posterior  wall  of  the  cervix. 

J.  Bernard  Browne,  of  Baltimore,^  makes  an  incision  through  the 
fundus.  A  strong  dilator  then  is  passed  through  the  opening  into  the 
constricted  ring,  and  the  cervix  is  dilated  until  the  corpus  can  be 
forced  through  into  place.  Just  before  reposition  the  wound  in  the 
corpus  is  closed  with  catgut  sutures.  Intra-uterine  gauze  drainage 
may  be  used  in  place  of  closing  the  opening.  These  and  similar 
methods  of  incision  before  the  days  of  aseptic  surgery  were  regarded 
as  extra-hazardous,  and  therefore  were  disapproved  generally.  With 
an  aseptic  field  of  operation  the  risk  should  not  be  greater  than  that 
of  other  operations  involving  peritoneal  incisions  of  equal  extent. 

The  method  of  Thomas  to  open  the  abdomen,  and  that  of  Kiistner 
to  open  from  the  vagina  into  Douglas'  pouch,  in  order  to  reach  and 
directly  dilate  the  cervix  on  the  peritoneal  side,  have  given  good  results. 

A  thoroughly  satisfactory  operation  is  that  of  Spinelli,  the  technique  of 
which  is  given  herewith.  Figures  429  to  436  is  a  series  of  illustrations 
published  by  Reuben  Peterson.^ 

Hysterectomy. — If  all  efforts  of  taxis,  elastic  pressure,  and  inci- 
sion have  failed,  removal  of  the  uterus  may  become  a  final  resource. 
The  operation  ordinarily  would  be  vaginal  hysterectomy,  and  would 
be  performed  substantially  as  already  described  for  cancer.  The  writer 
suggests  that  after  the  posterior  and  anterior  incisions  have  been  made 
from  the  vagina  into  the  peritoneal  cavity,  another  attempt  at  reposi- 
tion be  made.  Through  these  openings  great  force  could  be  applied 
by  the  mechanical  principle  employed  in  the  method  of  Tate.  The 
fingers  should  be  introduced  not  into  the  rectum  and  vagina,  but  tlirough 
the  vaginal  incisions.  Counterpressure  then  could  be  made  most 
powerfully  direct  against  the  cervical  ring. 

•  New  York  Medical  Journal.  November  24.  1883. 

2  Transactions  of  the  American  Gynecological  Society,  1907. 


724 


DISPLACEMENTS 

Figure  429 


Spinelli's  operation,  first  step:  The  inverted  uterus  is  drawn  downward  with  traction  forceps. 
The  anterior  vaginal  wall  is  made  tense  by  upward  traction  and  the  anterior  vaginal  wall  incised 
just  above  the  anterior  cervical  lip  by  a  transverse  incision.  There  is  no  danger  of  cutting  into  the 
bladder,  which  is  situated  higher  up. 


Figure  430 


tipineili's  operation,  second  step:    The  anterior  cervical  lip  is  steadied  by  a  forceps  at  either  angle. 

pulling  outward. 


i.whh'sinx  or  nil':  ctercs 

Fl.lfUK     ».J1 


725 


Spinelli's  operation,  third  step:  'VN'ith  the  forefinger  placed  in  the  ring  as  a  guide,  the  anterior 
uterine  wall  is  incised  from  the  external  os  to  the  fundus,  or  as  far  as  may  be  necessary-  for  the  accom- 
plishment of  the  reinversion. 


Figure  432 


Spinelli's  operation,  fourth  step:  The  split  uterus  is  now  reinverted  through  pressure  upward  by 
the  thumbs  and  pulling  outward  by  the  index  fingers.  This  is  usually  easily  accomplished  without 
tearing  of  the  uterine  tissues. 


726 


DISPLACEMENTS 

Figure  433 


Spinelli's  operation,  fifth  step:  After  the  reinversion  has  been  accomphshed  there  is  a  kind  of 
ectropion  of  the  uterine  walls,  so  that  the  peritoneal  edges  will  not  come  together.  To  bring  this 
about,  a  wedge-shaped  piece  should  be  removed  from  each  side  of  the  incision.  Notice  that  the  fundus 
has  been  carried  upward,  while  the  cervix  is  now  downward. 


Figure  434 


Spinelli's  operation,  sixth  step: 


Line  of  incision  is  now  sutured, 
used,  if  desired. 


Two  layers  of  sutures  may  be 


INVERSION  OF  THE  UTERUS 

FiouuK  435 


'27 


Spinelli's  operaliuii.  s^-venth  step:  The  fua<iu6  iias  ocl-u  replaced  wiiJuiii  the  pelvic  cavity  through 
the  transverse  vaginal  incision.  If  there  be  a  tendency  for  the  uterus  to  drop  backward,  the  round 
ligaments  may  be  shortened. 


Figure  436 


Spinelli's  operation,  eighth  step:    The  transverse  vaginal  incision  is  closed  except  a  small  aperture 

for  drainage. 


728  DISPLACEMENTS 


HERNIA  OF  THE  UTERUS   AND   OVARY 

A  common  form  of  hernia  of  the  uterus  has  been  described  in  the 
chapter  on  Descent  of  the  Uterus. 

Hysterocele,  or  hernia  of  the  uterus  through  the  inguinal  canal  or 
inguinal  rings,  is  a  rare  and  remarkable  displacement.  Cases  have 
been  reported  by  Olshausen,  Leopold,  Rectorzik,  Winckel,  and  Scanzoni 
of  displacement  of  the  uterus  into  the  sac  of  a  crural  or  inguinal  hernia. 
In  two  cases  the  displacement  was  complicated  by  pregnancy,  which 
continued  to  the  fourth  month. 

The  Diagnosis  is  based  upon  the  absence  of  the  uterus  from  its 
normal  place  and  the  presence  in  the  hernial  sac  of  a  body  answering 
its  description.  If  pregnant,  the  uterus  will  increase  progressively 
in  size  until  relieved  by  abortion. 

The  Treatment  is  the  same  as  for  any  other  form  of  hernia.  If 
reduction  by  taxis  is  unsuccessful,  herniotomy  becomes  necessary,'  and 
may  involve  removal  of  the  uterus. 

Hernia  of  the  ovary  may  occur  in  the  same  way  as  hernia  of  the  uterus, 
and  is  subject  to  the  same  principles  of  diagnosis  and  treatment.  The 
author  personally  has  seen  but  one  case;  which  was  treated  successfully 
by  herniotomy  and  removal  of  the  ovary. 


PAKT  vr 

DlSOrvDERS  OF  MENSTRUATIOxN  ANT)  STP]I1- 
ILITY^  AND  INCONTINENCE  OF  URINE 


CHAPTER  XLIV 

PREMATURE  MENSTRUATION  AND  PROTRACTED 
MENSTRUATION 

PREMATURE   MENSTRUATION 

It  is  clear  that  precocious  menstruation  could  not  occur  unless  the 
genital  organs  had  developed  prematurely;  and  that  in  the  absence  of 
such  de^'elopment  there  would  be  no  evidence  except  flow  of  blood  on 
which  the  fact  of  menstruation  could  be  established.  One  should  be 
cautious  in  drawing  conclusions  from  the  mere  presence  of  a  red  stain 
on  the  napkin  or  clothing,  for  such  a  stain  is  not  proof  of  menstrua- 
tion; it  may  be  blood  from  vulvovaginitis,  urethritis,  or  traumatism, 
or,  what  is  more  frequent,  from  deposit  of  red  urates. 

Development  of  the  sexual  organs  has,  in  rarely  exceptional  cases, 
taken  place  long  before  the  age  of  puberty,  and  in  some  instances  has 
been  observed  at  infancy.  Perfectly  developed  mammse,  a  full  growth 
of  hair  on  the  mons  \'eneris,  extensive  development  of  the  external  gen- 
erative organs,  and  great  precocity  of  the  internal  organs  have  been 
observed  in  infancy  and  in  early  childhood.  In  many  instances  of  pre- 
cocious development  premature  menstruation  did  not  occur;  in  others 
it  made  its  appearance  several  years  before  the  normal  age  of  puberty; 
and  in  one  or  two  attested  cases  apparently  physiological  menstruation 
occurred  soon  after  birth. 

As  above  stated,  the  appearance  of  a  bloody  discharge,  even  though 
it  be  periodical,  is  not  necessarily  to  be  attributed  to  menstruation. 
Such  a  discharge  may  occur  as  the  result  of  tumors,  erosions,  ulcera- 
tions, and  other  pathological  causes,  at  any  period  of  life,  from  infancy 
to  old  age. 

1  The  disorders  of  menstruation  and  sterility  are  merely  functional,  and  therefore  must  be  con- 
sidered, not  as  diseases,  but  as  symptoms.  In  studj-ing  these  symptoms  it  is  essential  to  consider 
them  from  the  standpoint  of  the  multiform  lesions  that  cause  them.  There  is  scarcely  a  gynecological 
di.sease  that  may  not  have  relation,  direct  or  remote,  with  functional  disorders.  Part  VI,  in  a  certain 
sense,  therefore,  is  an  index  to  the  whole  subject  of  gynecology.  In  connection  with  the  .study  of  these 
disorders,  it  will  be  profitable  to  read  the  first  chapter  of  the  book,  which  contains  a  condensed  state- 
ment of  the  phenomena  of  menstruation. 

(729) 


730  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

The  evidence  of  many  notable  examples  of  early  pregnancy  is  un- 
questioned; Croom  tabulated  from  the  literature  a  series  of  twelve 
cases  in  which  pregnancy,  occurring  in  girls  of  ages  varying  from  eight 
to  thirteen  years,  resulted,  with  one  exception,  in  the  delivery  of  mature 
infants. 

Causes  of  Premature  Menstruation 

The  causes  of  precocious  sexual  development  and  premature  men- 
struation, especially  in  infantile  cases,  are  not  satisfactorily  explained. 
Among  the  alleged  causes  are;  1,  heredity;  2,  immoral  associations, 
which  viciously  direct  the  attention  of  the  child  to  the  generative 
organs;  3,  masturbation;  4,  ascarides  in  the  rectum  and  other  para- 
sites about  the  external  genitals;  5,  uncleanliness,  especially  the  de- 
position of  caseous  secretions  about  the  clitoris;  6,  neoplasm  of  the 
generative  organs;  7,  undue  nervous  and  mental  excitement. 

Treatment  of  Premature  Menstruation 

The  treatment  is  implied  in  the  preceding  paragraph;  it  consists 
in  the  removal  of  the  cause.  The  necessity  for  cleanliness  and  chastity 
is  self-evident.  A  young  girl  prone  to  precocity  should  be  guarded 
against  all  influences  that  tend  to  stimulate  the  emotions  or  to  provoke 
sexual  excitation.  The  treatment  is  rather  regulative  than  medicinal, 
is  chiefly  hygienic,  and,  as  such,  includes  careful  attention  to  diet, 
exercise,  recreation,  sleep,  and  study. 


PROTRACTED   MENSTRUATION 

The  normal  menopause  usually  takes  place  between  the  ages  of 
forty-five  and  fifty  years;  it  may  occur  earlier,  or  as  late  as  the  fifty- 
third  year;  but  cessation  of  menstruation  before  the  fortieth  year  or 
the  continuance  of  it  later  than  the  fifty-second  year  would  be  pre- 
sumptive evidence  of  a  pathological  cause.  Apparently  normal  men- 
struation, however,  has  been  known  to  continue  until  after  the  age  of 
fifty-seven.  The  coexistence  of  ovulation  with  late  menstruation  in 
a  given  case  can  be  established  only  by  the  occurrence  of  pregnancy; 
of  this  occurrence  little  satisfactory  proof  has  been  recorded  after  the 
fifty-second  or  at  most  the  fifty-fourth  year.  The  evidence  is  con- 
clusive, therefore,  that  these  ages  are  the  practical  limit  of  possible 
fertility.^  The  author  observed  a  case  of  tubal  pregnancy  in  a  woman, 
fifty-four  years  old. 

1  AUbutt  and  Playfair.     System  of  Gynecology. 


CHAPTER   XLV 
AMEXORIUKEA  AXI)  SCANTY  MENSTRUATION 

AMENORRHEA 

Amenorriicea  is  the  absence  of  menstruation.  The  su})ject  is 
restricted  here  to  amenorrhoea  dependent  upon  pathological  or  surgical 
causes,  and  excludes  the  physiological  absence  of  menstruation  before 
puberty,  during  gestation  and  the  puerperium,  and  after  the  meno- 
pause; it  also  exckides  all  cases  in  which  menstrual  fluid,  having  been 
retained  by  atresia  in  the  genital  tract,  fails  to  make  its  appearance. 
See  Chapter  XXXV. 

Classification 

Two  general  divisions  of  amenorrhoea  have  been  recognized:  1. 
The  disorder  may  be  due  to  absence  of  the  reproductive  organs  or  to 
failure  of  those  organs  to  develop  from  the  immaturity  of  infancy  to 
the  maturity  of  puberty.  2.  Menstruation  may  have  been  established 
at  puberty,  and  from  pathological  causes  may  have  ceased.  These 
two  divisions  are  designated  as  primary  and  secondary  amenorrhoea. 

Etiology  of  Amenorrhoea 

The  causes  may  be  divided  into: 
I.  Local  causes. 
II.  General  causes. 

I.  Local  Causes. — Chief  among  the  local  causes  are  absence,  im- 
perfect development,  and  atrophy  of  the  uterus  and  its  appendages. 
The  relative  extent  of  these  defects  may  be  greater  in  the  uterus  and 
less  in  the  appendages;  or  greater  in  the  appendages  and  less  in  the 
uterus.  Absence  or  imperfect  development  of  the  genitals  may  coexist 
with  perfect  development  of  the  body  in  general.  There  are  two 
forms  of  uterine  atrophy;  concentric,  in  which  the  uterus  is  much 
contracted  and  its  canal  correspondingly  shortened;  and  excentric,  in 
which  the  atrophic  process  has  resulted  in  a  thinning  of  the  walls 
without  decrease  in  the  length  of  the  uterine  canal. 

Endometritis  and  metritis,  especially  when  associated  with  an  in- 
fectious puerperium,  may  give  rise  to  atrophy  of  the  uterus  and  con- 
sequent amenorrhoea.  See  Chapter  XVI.  Ovaritis  may,  as  a  cause 
of  atrophy  of  the  ovary,  produce  the  same  result.  Microcystic 
degeneration  of  the  ovaries  and  ordinary  bilateral  ovarian  cysts  are 
associated  frequently  with  atrophy  of  the  ovary  and  amenorrhoea. 

(731) 


732  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

Atrophy  of  the  uterus  and  ovaries,  especially  of  the  former,  has 
been  observed  occasionally  to  follow  sharp  curettage  for  endometritis. 

II.  General  Causes  seldom  produce  amenorrhoea  by  acting  directly 
per  se;  they  usually  do  so  indirectly  by  causing  atrophy  of  the  uterus 
or  ovaries,  or  of  both.    They  may  be  classified  as  follows: 

1.  Acute  infectious  diseases. 

2.  Chronic  disorders. 

3.  Nervous  disorders. 

1.  Acute  Infectious  Diseases  include  scarlatina,  diphtheria,  typhoid 
fever,  and  arthritic  rheumatism.  The  same  infection  that  produces 
these  diseases  may  produce  also  atrophy  of  the  uterus  or  ovaries. 

2.  Chronic  Disorders. — Among  the  chronic  disorders  that  cause 
amenorrhoea  are  tuberculosis,  diabetes,  syphilis,  anaemia,  nephritis, 
chlorosis,  myxoedema,  malaria,  and  exophthalmic  goitre.  Amenorrhoea 
associated  with  these  disorders  may  not  be  consequent  upon  atrophy; 
it  may  be  simply  an  effort  of  nature  to  conserve  the  blood  and  strength 
of  a  woman  whose  general  nutrition  would  suffer  even  from  slight  men- 
struation. In  some  cases  anaemia  is  associated  with  uterine  hemor- 
rhage.   See  Chapter  XLVII. 

3.  Nervous  and  Mental  Disorders. — ^The  psychoses,  especially  those 
causing  great  mental  depression,  are  likely,  with  or  without  atrophy 
of  the  uterus,  to  be  associated  with  amenorrhoea.  The  influence  of  the 
nervous  system  is  manifest  in  the  amenorrhoea  of  prisoners  and  in- 
mates of  asylums.  Sudden  emotion,  chill,  and  fright  have  been  known, 
temporarily  or  permanently,   to  arrest  menstruation. 

In  addition  to  the  above  causes  may  be  metitioned  the  following: 
excessive  hemorrhage,  especially  from  the  genitals;  superin volution 
of  the  uterus  from  prolonged  lactation;  tissue-change  of  unknown 
origin;  the  morphine-habit;  and  faulty  hygiene,  especially  such  hygiene 
as  comes  from  insufficient  food,  overwork,  and  vitiated  air. 

Adiposity  in  ansemic  women  is  often  the  cause  of  amenorrhoea;  the 
menstrual  disorder,  however,  sometimes  disappears  with  removal  of 
the  cause.  The  physiological  amenorrhoea  of  the  menopause  is  fol- 
lowed not  uncommonly  by  deposition  of  fat. 

The  amenorrhoea  of  delayed  puberty  may  occur  in  girls  whose 
generative  organs  are  apparently  well  developed.  Failure  to  men- 
struate in  such  cases  may  be  due  to  one  or  more  of  the  general  causes 
already  outlined.  In  some  cases  of  apparently  robust  health  the  patient, 
for  reasons  unknown,  fails  to  menstruate.  The  girl  may  at  the  period 
of  puberty  menstruate  normally,  and  after  a  year  or  two  may  men- 
struate less  and  less,  and  perhaps  finally  cease  altogether.  In  too 
many  such  cases  the  amenorrhoea  is  due  doubtless  to  diversion  of 
energy,  which  should  be  used  in  the  building  up  of  the  reproductive 
system,  to  social  and  mental  requirements.  If  this  energy  is  diverted 
.to  the  brain  or  to  the  ball-room,  the  reproductive  system  may  suffer. 

Removal  of  the  ovaries  in  the  great  majority  of  cases  will  arrest 
menstruation  immediately.  The  causes  of  continued  menstruation 
after   double   ovariotomy   are:  1,   the   presence   of   a   supernumerary 


AMKSORRIKKA    AM)  ^CASTY   M ESST IH' ATION  T.'vi 

()\;iry;  '2,  t'iiilure  to  riMiioNc  all  of  the  oxariaii  tissiR*;  '.\,  failure  to 
rcMiiox'c  the  tubes  elose  into  the  horns  of  tlie  uterus;  4,  diseases  of 
the  uterus,  i.  e.,  entlonietritis,  earcinoma,  and  fibroids;  5,  persistence 
of  liabit. 

Symptoms  of  Amenorrhoea 

Absence  of  menstruation  is  the  prime  symptom;  associated  with 
tliis  may  be  numerous  disturbances  referable  to  the  nervous  system; 
among  them,  (h^fective  vision,  ringing  in  the  ears,  hysteria,  paresis, 
sweating,  and  such  skin-eruptions  as  acne,  urticaria,  eczema,  and  herpes. 
Amenorrha?a  often  is  associated  with  all  the  symptoms  of  menstrua- 
tion except  the  flow — these  symptoms  taken  together  are  termed 
the  molimen. 

]'icarious  menstruation  is  an  infrequent  occurrence.  Numerous 
remarkable  cases,  however,  have  been  reported  in  which  a  periodic 
flow  of  blood  from  some  organ  other  than  the  uteruS  apparently  took 
the  place  of  normal  menstruation.  Such  a  flow  may  come  from  the  nose, 
ear,  bowel,  or  bronchi,  or  from  any  exposed  surface,  such  as  an  ulcer; 
it  may  be  accompanied  by  a  discharge  of  milk  from  the  breasts  or  with 
diarrhoea.    The  cause  of  vicarious  menstruation  is  unknown. 


Diagnosis  of  Amenorrhoea 

Inasmuch  as  amenorrhoea  is  a  symptom  and  not  a  disease  the  object 
of  diagnosis  must  be  to  recognize  the  lesion  or  lesions  that  underlie 
and  perpetuate  the  symptom.  Amenorrhoea,  especially  that  caused 
by  atrophy  of  the  ovaries,  is  characterized  sometimes  by  the  presence 
of  a  peculiar  menstrual  molimen  above  mentioned,  unaccompanied 
by  a  flow  of  blood,  but  attended  with  great  ovarian  hypogastric  and 
lumbar  pain. 

Prognosis  of  Amenorrhoea 

The  prognosis  is  that  of  the  lesion  that  produces  the  amenorrhoea. 
Primary  amenorrhoea,  due  to  absence  of  the  uterus  or  ovaries,  is  per- 
manent. Full  development  of  the  rudimentary  organs  and  consequent 
menstruation  ha\'e  been  reported  in  rare  instances;  but  these  reports 
are  not  sufficiently  definite  to  have  practical  significance. 

Excentric  atrophy  of  the  uterus,  that  does  not  decrease  the  length 
of  the  organ,  but  only  thins  its  walls,  may,  on  removal  of  the  cause 
and  the  establishment  of  correct  hygiene,  terminate  in  anatomical 
and  physiological  recovery;  concentric  atrophy,  in  which  the  uterus 
is  contracted  uniformly,  is  permanent.  As  a  rule  atrophy  due  to  in- 
fection, especially  to  an  infectious  puerperium,  is  permanent. 

Amenorrhoea  due  to  prolonged  lactation,  or  to  nervous  causes, 
such  as  sudden  fright  or  violent  emotion  or  chill,  "offers  a  favorable 
prognosis. 


734  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

In  general,  the  prospect  of  recovery  is  good  for  all  cases  in  which 
atrophy  of  the  uterus  or  ovaries  is  only  a  participation  in  a  general 
systemic  failure  of  nutrition.  In  cases  of  defective  local  development 
and  of  atrophy  due  to  local  causes,  especially  to  infection,  the  amen- 
orrhoea  is  usually  permanent.  In  the  class  of  cases  mentioned  under 
etiology,  in  which  girls  in  apparently  robust  health  fail  to  menstruate  at 
puberty,  the  prognosis  is  not  necessarily  bad,  for  in  many  such  cases 
normal  menstruation  and  maturity  occur  after  marriage,  and  in  some 
such  cases  pregnancy  has  been  observed  even  though  the  amenorrhoea 
persisted. 

Treatment  of  AmenorrhcEa 

The  treatment  must  vary  with  the  cause.  Certain  forms  of  amen- 
orrhoea, mentioned  under  Prognosis,  are  permanent,  and  therefore 
incurable. 

The  curable  cases  are  usually  those  in  which  the  uterus  or  ovaries 
have,  because  of  some  wasting  disease,  such,  for  example,  as  tuber- 
culosis, failed  to  perform  their  functions.  Amenorrhoea  then  may, 
as  already  stated,  be  only  an  effort  of  nature  to  conserve  the  woman's 
blood  and  strength.  The  ill-health  should  not  be  attributed  to  want 
of  menstruation,  but  to  general  want  of  nutrition;  under  such  condi- 
tions treatment  designed  to  re-establish  menstruation  by  local  stimula- 
tion is  clearly  contraindicated.  Such  treatment  would  defeat  the 
efforts  of  nature  and  still  further  exhaust  the  woman's  \'itality  and 
strength.     The  treatment  should  be  riot  local,  but  systemic. 

Systemic  Treatment. — It  follows,  from  the  foregoing,  that  systemic 
treatment  must  be  that  of  the  numerous  causal  diseases  already  men- 
tioned, such  as  anaemia,  chlorosis,  myxoedema,  exophthalmic  goitre, 
malaria,  nephritis,  and  tuberculosis.  Among  the  most  reliable  medicinal 
remedies  are  iron,  arsenic,  manganese,  the  bitter  tonics,  salines,  and 
mineral  waters.  Hygienic  remedies,  such  as  nutritious  food,  exercise, 
rest,  bathing,  and  suitable  climate,  must  have  adequate  attention. 

In  amenorrhoea  due  to  obesity  and  associated  anaemia  the  indication 
is  to  improve  nutrition  by  cure  of  the  anaemia  and  reduction  of  the  fat. 

The  distressing  nervous  symptoms  mentioned  in  Chapter  I.,  that 
sometimes  follow  the  menopause,  should  be  treated  on  general  prin- 
ciples. The  treatment  indicated  for  these  symptoms  is  the  same 
whether  the  menopause  occurs  from  natural  causes  or  is  produced 
artificially  by  removal  of  the  uterine  appendages.  Ovarian  extract  in 
3-grain  doses,  taken  three  times  a  day,  apparently  has  given  much 
relief.     Corpus  luteum  extract  is  perhaps  even  more  effective. 

Local  Treatment  is  generally  useless.  In  some  cases  it  appears 
to  have  been  effective;  but  the  improvement  probably  resulted  from 
general  nutritional  changes.  Pelvic  congestion  sometimes  associated 
with  suppression  of  the  menses  may  be  relieved  by  rest  in  bed,  regu- 
lation of  the  bowels,  hot  water  vaginal  douche  (see  Chapter  IV.), 
glycerin  tamponade  in  the  vagina,  scarification  and  leeching  of  the 


AMENORRHCEA   AND  SCANTY  MENSTRUATION  735 

cervix.     IVKic  anit^mia  associated  with  aiiUMiorrlid'a  is  an  indication 
for  pcKic  niassai;;c  and  ^^yinnastics. 

Klcctricity  a])j)lie(l  to  the  i)clvic  organs,  whether  from  the  ordinary 
battery  or  from  the  zinc  and  copper  pessary,  is  of  questionable  value. 


SCANTY   MENSTRUATION 

Scanty  menstruation,  like  menorrhagia,  is  a  relative  condition.^ 
The  normal  flow  may  vary  for  different  women  between  two  and  six 
days — that  is,  a  flow  of  two  days'  duration,  for  exam{)le,  ma>'  be  nor- 
mal for  a  woman  who  cannot  afford  to  lose  much  lilood,  while  for  a 
very  plethoric  woman  a  much  longer  period  of  ffow  might  be  normal. 
A  material  decrease  or  increase,  how^ever,  in  the  number  of  days  f)r  in 
the  amoimt  normal  for  a  given  individual  should  give  rise  to  suspicion 
of  a  pathological  cause.  The  woman's  menstrual  habit  therefore  must 
be  considered  in  the  diagnosis. 

The  causes  of  scanty  menstruation  are  identical  with  those  already 
laid  down  as  the  causes  of  amenorrhoea;  the  same  etiology  being  estab- 
lished, it  follows  that  the  pathology,  diagnosis,  and  treatment  must 
also  be  along  the  same  lines. 

1  Croom.     System  of  Gynecology,  AUbutt  and  Playfair. 


CHAPTER  XLVI 

UTERINE  HEMORRHAGE— MENORRHAGIA  AND 
METRORRHAGIA 

Menokrhagia  is  excessive  loss  of  blood  from  abnormally  profuse 
or  abnormally  prolonged  menstruation.  Loss  of  blood  from  the  uterus 
in  the  interval  between  the  end  of  one  menstruation  and  the  beginning 
of  the  next,  whether  scanty  or  profuse,  is  known  as  metrorrhagia.  Hem- 
orrhage from  such  causes  as  placenta  prsevia,  degeneration  of  the  chorion 
and  inversion  of  the  uterus,  is  described  in  works  on  obstetrics. 

The  terms  menorrhagia  and  metrorrhagia,  although  in  general  use, 
cannot  be  applied  always  with  accuracy.  The  menstrual  flow  may  be 
prolonged  throughout  the  greater  part  of  the  month,  or  may  cease 
altogether  for  intervals  of  hours  or  days.  It  is  therefore  evident  that 
menstrual  hemorrhage — menorrhagia — and  intermenstrual  hemorrhage 
— metrorrhagia — may  be  indistinguishable.  It  is  quite  as  well  to  use 
the  more  simple  term,  uterine  hemorrhage. 

Etiology  of  Uterine  Hemorrhage 

Certain  disorders  which,  if  present,  are  apt  to  cause  uterine  hemor- 
rhage will  be  found  described  more  fully  in  other  parts  of  the  book 
that  especially  treat  of  them.  Among  the  more  common  of  these 
conditions  are: 

1.  Inflammations.  4.  Foreign  bodies. 

2.  Tumors.  5.  Systemic  disorders. 

3.  Displacements.  6.  Visceral  diseases. 

7.  Uterine  moles. 

1.  Inflammations. — The  inflammatory  causes  of  uterine  hemorrhage 
may  be  uterine  or  extra-uterine. 

Uterine  Inflammations. — Chronic  glandular  endometritis,  as  de- 
scribed in  Chapter  XVI.,  is  characterized  by  enlargement  of  the  gland- 
ular and  vascular  structures  of  the  endometrium,  and  by  consequent 
excessive  glandular  secretion,  or  hemorrhage,  or  both  combined.  From 
the  pathology,  therefore,  it  is  easy  to  understand  that  an  excessive 
flow  due  to  endometritis  is  mixed  ordinarily  with  glandular  secretions; 
that  these  secretions  may  form  a  very  considerable  part  of  the  abnormal 
menstrual  discharge;  and  that  in  some  cases  in  which  the  disease  is 
more  glandular  than  vascular  the  discharge  may  be  almost  entirely 
a  profuse  uterine  leucorrhoea  composed  of  vitiated  mucus  or  mucopus, 
and  only  slightly  admixed  with  blood.  Such  a  discharge,  if  profuse, 
even  though  it  contains  no  blood,  may  be  quite  as  exhausting  as  if 
it  were  of  a  pronounced  hemorrhagic  character. 
(736) 


.  UTERI XK   HEMORRHAGE  737 

Arteriosclerosis  of  the  uterine  \essels  alone  has  been  assigned  as 
the  cause  of  uncontrollable  uterine  hemorrhage  by  Herman,  August 
Martin,  Reinscke,  and  Kiistner.  After  a  careful  review  of  the  few 
recorded  cases,  Findley  concludes  that  arteriosclerosis,  per  se,  is  not 
an  adequate  cause  of  uterine  hemorrhage.  In  all  the  reported  cases 
there  were  other  conditions  which  had  resulted  in  obstruction  to  the 
general  circulation,  such  as  Bright 's  disease,  heart  lesions,  pulmonary 
infection,  and  thrombosis  of  the  uterine  vessels.  In  the  case  recorded 
by  Findley  arteriosclerosis  and  calcification  of  the  uterine  vessels 
undoubtedly  existed  long  before  the  beginning  of  the  hemorrhage. 
In  this  case  embolic  infarction  of  the  uterus  from  a  thrombus  in 
the  heart  was  the  immediate  cause  of  hemorrhage.^  See  Chronic 
Metritis. 

Extra-uterine  Inflammations,  such  as  ovaritis,  salpingitis,  parame- 
tritis, and  perimetritis,  give  rise  to  pelvic  congestion  and  to  a  conse- 
cjuent  efl'ort  of  nature  to  obtain  relief  by  an  increased  flow.  Ovaritis, 
according  to  its  nature,  may  increase  or  diminish  menstruation.  Par- 
enchymatous inflammation  in  the  cortical  substance  of  the  ovary  may 
increase  the  flow.  On  the  contrary,  the  atrophic  process  of  interstitial 
o\aritis  or  of  microcystic  degeneration  of  the  ovary,  tends  to  induce 
amenorrhoea. 

2.  Tumors. — Uterine  tumors  cause  excessive  menstruaton  in  greater, 
or  less  degree  according  to  their  situation.  A  growth  beginning  in  close 
relation  with  the  endometrium  and  developing  within  the  uterine 
cavity  may  set  up  a  dangerous  periodic  or  constant  bleeding;  if  situ- 
ated in  the  uterine  wall,  between  the  endometrium  and  the  peri- 
metrium, it  may  excite  little  more  than  the  normal  flow;  located  near 
the  peritoneal  covering,  it  may,  especially  if  pedunculated,  give  rise 
to  no  menstrual  excess  whatever;  uterine  myoma,  for  example,  may, 
according  as  it  is  submucous,  intramural,  or  subperitoneal,  cause 
much,  little,  or  no  menorrhagia. 

A  tmnor  may  set  up  excessive  flow  in  one  or  both  of  two  ways:  1. 
The  irritation  of  its  presence  may  give  rise  to  a  hemorrhagic  endome- 
tritis. 2.  Ulcerative  processes  or  friability  of  the  tumor  itself  may 
cause  rupture  of  blood-vessels  and  hemorrhage.  In  one  way,  the  blood 
comes  from  the  endometrium;  in  the  other,  from  the  tumor.  Myomata, 
being  slow  to  ulcerate  and  break  down,  are  little  liable  to  bleed  per  se; 
but  if  submucous,  they  irritate  the  endometrium  and  set  up  hemorrhagic 
endometritis.  Cancer  and  sarcoma  not  only  cause  hemorrhagic  endo- 
metritis, but  themselves  rapidly  undergo  necrotic  changes,  and  thus 
become  the  source  of  hemorrhage.  Extra-uterine  growths  may  induce 
menorrhagia  by  the  pelvic  irritation  and  consequent  congestion  to 
which  they  give  rise. 

3.  Displacements. — Deviations  of  the  uterus  and  its  appendages, 
through  traction  on  the  pelvic  blood-vessels,  may  so  obstruct  the  cir- 
culation as  to  cause  venous  congestion  and  a  consequent  excessive 

•  "Arteriosclerosis  of  the  Uterus."     Findley,  American  Journal  of  Obstetrics,  1901,  Xo.  1,  vol.  xliii. 

'45 


738  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

menstrual  effort  to  lessen  the  quantity  of  blood  in  the  pelvis.  The 
complete  relief  from  menorrhagia  that  sometimes  follows  the  correc- 
tion of  a  prolapsed  or  flexed  uterus  by  means  of  artificial  support, 
and  the  prompt  return  of  excessive  menstruation  upon  withdrawal  of 
the  support,  are  satisfactory  proof  that  displacement  may  cause  uterine 
hemorrhage.  Further  information  on  this  subject  may  be  found  in 
Part  V,  on  Displacements. 

4.  Foreign  Bodies. — Tents  and  other  foreign  bodies  which  find 
their  way  into  the  uterus  either  from  therapeutic  or  criminal  motives 
may,  by  their  irritating  presence,  cause  excessive  flow.  An  embryo 
detached  in  the  course  of  abortion  is  a  familiar  example  of  foreign 
body  in  the  uterus. 

5.  Systemic  Disorders.^ — Any  general  disorder  that  will  embar- 
rass the  return  flow  of  blood  from  the  pelvic  viscera  will  cause  an 
increased  vascular  pressure  that  may  result  in  hemorrhage  from  the 
uterus.  Among  the  systemic  conditions  that  may  underlie  excessive 
menstruation  are:  hemorrhagic  diathesis,  scorbutus,  purpura,  malaria, 
lead-poisoning,  and  acute  infectious  diseases,  such  as  scarlet  fever, 
diphtheria,  and  typhoid  fever.  Menorrhagia  associated  with  such 
causes  is  often  difficult  to  treat,  because,  as  Croom  says,  these  causes 
interact  in  such  a  way  as  to  form  a  vicious  circle — the  drain  on  the 
system  from  the  hemorrhage  tending  to  aggravate  the  systemic  con- 
dition, which  in  its  turn  leads  to  the  menorrhagia.  Chronic  mental 
depression,  hysteria,  sedentary  habits,  and  residence  in  high  altitudes 
or  the  tropics,  ah,  in  greater  or  less  degree,  dispose  to  menorrhagia. 
In  some  cases  anaemia,  although  usually  a  cause  of  amenorrhoea  or 
scanty  menstruation,  may  cause  uterine  hemorrhage.  This  is  explained 
possibly  by  the  low  specific  gravity,  the  diminished  coagulability  of  the 
blood,  or  faulty  nutrition  of  the  vessels. 

6.  Visceral  Diseases. — Heart  diseases,  such  as  hypertrophy,  dila- 
tation, mitral  insufficiency,  or  stenosis,  as  well  as  cirrhotic  changes  in 
the  liver  or  kidney,  are  associated  usually  with  such  organic  change 
or  functional  disturbance  in  the  blood-vessels  as  to  cause  embarrass- 
ment of  circulation  and  hemorrhage  in  various  organs.  Under  one 
or  more  of  the  disorders  just  named,  the  uterus,  being  the  seat  of  a 
normal  periodic  hemorrhage,  and  being  therefore  predisposed  to  hem- 
orrhage, may,  especially  if  there  be  disease  of  the  endometrium,  readily 
become  the  medium  of  exaggerated  menstruation. 

7:  Uterine  Moles. — Among  the  occasional  causes  of  uterine  hem- 
orrhage may  be  mentioned  uterine  moles.  There  are  two  varieties: 
1,  fleshy  mole;  2,  hydatiform  mole,  sometimes  called  cystic  mole,  and 
sometimes  wrongly  called  uterine  hydatids. 

Fleshy  Mole. — ^The  so-called  fleshy  mole  is  associated  sometimes 
with  hemorrhage  from  the  uterus,  and  when  so  associated  gives  rise 
to  abnormal  signs  of  pregnancy.  It  may  be  recognized  upon  spon- 
taneous expulsion  or  removal. 

1  Croom.     System  of  Gynecology,  Allbutt  and  Playfair. 


UTERINE  HEMORRHAGE  730 

Hydatiform  Mole  is  the  result  of  cystic  dc^'ciicration  of  the  cliorioiiic 
villi.  It  <;i\cs  rise  to  proiioiiuccd  and  constant  or  almost  constant 
hemorrhage,  and  is  associated  with  rapid  increase  in  the  si'/e  of  tiie 
uterus,  together  with  the  usual  signs  of  pregnancy.  The  diagnosis  will 
de])end  u])on  the  expulsion  of  a  i)art  or  all  of  the  vesicles.  Although 
hydatiform  mole  and  hydatids  (echiuococcus)  resemble  one  another 
in  gross  appearance,  they  have  no  other  characteristic  in  common. 
Uterine  hydatids  (echiuococcus)  have  been  obser\e(l,  but  they  are  of 
very  rare  occurrence. 

When  the  causes  of  menorrhagia  are  so  obscure  that  they  cannot  be 
detected,  the  hemorrhage  has  been  termed  idiopathic.  The  use  of 
such  a  term  explains  nothing.  It  is  better  to  say  outright  that  the 
symptom  is  of  unknown  origin.  Some  light  is  shed  upon  this  class  of 
causes  by  the  following  resume  made  from  an  article:  "Studies  on  a 
Local  Hematological  Factor  in  the  Causation  of  Uterine  Hemorrhage," 
by  Dr.  Arnold  Sturmdorf,  New  York  State  Journal  of  Medicine, 
October,  1911. 

Uterine  hemorrhage  presents  itself  under  two  categories.  In  the 
first  of  these  an  examination  of  the  patient  reveals  cause  for  the  abnormal 
bleeding,  while  in  the  second  no  such  cause  is  in  evidence.  The  second 
category  reveals  those  cases  occurring  at  the  two  extremes  of  men- 
strual life,  namely,  the  adolescent  and  preclimacteric  periods,  in  which 
no  palpable  cause  for  the  excessive  or  protracted  bleeding  from  the 
uterus  can  be  elicited. 

After  going  over  the  literature,  and  as  the  result  of  various  experi- 
ments, Sturmdorf  arrives  at  the  following  conclusions  relative  to  the 
second  class. 

1.  The  general  circulating  blood  during  the  menstrual  period  and 
in  the  hemorrhagic  conditions  here  considered,  shows  normal  coagu- 
lative  properties. 

2.  During  menstruation,  and  such  hemorrhage,  the  endometrium 
receives  normally  coagulable  blood  from  the  general  circulation  and 
gives  vent  to  this  blood  in  a  non-coagulable  state. 

3.  The  non-coagulability  in  the  menstrual  and  hemorrhagic  blood, 
discloses  an  identity  in  experimental  and  clinical  manifestations, 
differing  only  in  degree. 

4.  Under  the  giN'en  conditions  the  endometrium  exercises  a  function 
capable  of  rendering  coagulable  blood  non-coagulable. 

5.  This  function  is  due  to  the  lyresence  of  an  inhibiting  substance 
generated  in  loco  and  is  not  the  result  of  a  dialytic  process,  as  suggested 
hy  Cristae  and  Denk. 

6.  The  non-coagulable  blood  contains  all  of  the  essentials  to  coagu- 
lation, nevertheless,  this  blood  is  capable  of  inhibiting  coagulation  in 
the  normal  blood  taken  from  the  same  indixidual.  All  of  which  tend 
to  warrant  the  assumption  that  the  inhibitive  element  preventing 
coagulation  in  the  menstrual  blood,  probably  augmented  in  activity 
by  contributory  structural  abnormalities,  presents  a  local  causative 
factor  in  the  production  of  uterine  hemorrhage. 


740  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

Diagnosis  of  Uterine  Hemorrhage 

Before  deciding  what  constitutes  an  excessive  loss  of  blood,  it  is 
necessary  to  adopt  at  least  an  approximate  standard  of  the  normal 
amount.  As  stated  in  the  chapter  on  Scanty  Menstruation,  menor- 
rhagia  is  a  relative  condition.  An  anaemic  woman  whose  blood  is  scarcely 
sufficient  to  meet  the  fixed  requirements  of  nutrition  can  ill  afford  to 
spare  what,  in  a  robust  state,  would  be  even  less  than  normal;  and  for 
such  a  woman  amenorrhoea  may  be  a  means  of  saving  much  needed 
blood,  and  in  a  relative  sense,  therefore,  may  be  considered  normal. 
On  the  other  hand,  in  an  exceptional  case  of  plethora,  eight  or  nine 
days  of  free  menstruation  may  cause  no  ill  effect — may,  indeed,  be 
beneficial,  and  therefore  normal.  We  may,  however,  for  practical 
purposes  arbitrarily  limit  the  normal  duration  of  fnenstruation  to  six 
days,  and  the  number  of  napkins  soiled  in  that  time  to  about 
fifteen. 

In  the  diagnosis  of  menorrhgia,  one  must  exclude  all  bleeding  from 
extra-uterine  sources,  such  as  the  bleeding  from  hemorrhagic  vulvo- 
vaginitis, from  traumatism  of  the  vulva  or  vagina,  and  from  varicose 
veins  of  the  vulva. 

The  mere  discovery  of  menorrhagia  is  only  the  recognition  of  a  symp- 
tom. The  practical  diagnosis  includes  as  well  the  discovery  of  the  cause 
or  causes  of  that  symptom.  Only  in  this  way  is  a  rational  prognosis 
or  effective  plan  of  treatment  made  possible.  The  causes  that  produce 
menorrhagia  and  that  have  already  in  a  general  way  been  outlined  in 
in  preceding  paragraphs  of  this  chapter,  will  be  found  discussed  more 
fully  in  the  other  chapters  that  especially  treat  of  them. 

The  diagnosis  of  menorrhagia  will  vary  according  to  the  age  of  the 
patient  somewhat  as  follows: 

Uterine  Hemorrhage  in  Girls. — Inasmuch  as  the  menorrhagia  of 
girls  and  of  very  young  unmarried  women  is  in  a  very  large  propor- 
tion of  cases  due  to  general  systemic  conditions,  it  is  obvious  that 
uterine  examinations  in  such  cases  should  at  first  be  avoided.  If  the 
general  examination  has  failed  to  disclose  the  causative  lesion,  or 
general  treatment  has  failed  to  give  relief,  a  pelvic  examination  may 
be  the  only  means  of  diagnosis,  and  therefore  may  be  imperative.  It 
does  not,  however,  by  any  means  follow  that  a  minor  local  disturb- 
ance, even  though  coexistent  with  menorrhagia,  should  be  made  the 
occasion  of  local  treatment.  A  case  in  point  may  be  cited  from  the 
writer's  experience  in  which  there  were  protracted  menorrhagia  and 
increased  uterine  secretion,  both  promptly  disappearing  upon  correc- 
tion of  a  lateral  curvature  in  the  lumbar  region  of  the  spine  by  means  of 
a  plaster  jacket.  The  symptoms  complained  of  may  perhaps  have  been 
due  to  faulty  nutrition,  and  this  in  turn  may  have  been  perpetuated 
by  the  curvature;  at  any  rate,  whatever  the  explanation,  the  relief  was 
complete.  The  author  has  observed  one  case  of  profuse  menstruation 
and  intermenstrual  hemorrhage  in  a  young  girl  which  apparently  was 
due  to  chronic  appendicitis. 


UTERINE  HEMORRHAGE  741 

Uterine  Hemorrhage  during  the  Period  of  Maturity  is,  in  a  majority 
of  cases,  (IfjK'mK-iit  solely  or  partly  ujX)!!  local  pelvic  disease,  such  as 
infection,  displacements,  tnmors,  and  prodncts  of  conception.  Very 
commonly  the  local  disease  coexists  with  general  disorders.  Such 
cases  I'reciuently  demand  local,  f^eneral,  or  operative  treatment. 

Uterine  Hemorrhage  during  the  Menopause. — To  avoid  repeti- 
tion, the  reader  is  referred  to  a  partial  discussion  of  the  subject  in 
Chapter  I.  If  the  menopause  is  characterized  by  a  long-continued 
series  of  hemorrhages  or  by  constant  hemorrhage,  the  probability  is 
that  endometritis,  inflammation  of  the  uterine  appendages,  or  a  tumor 
exists,  and  retards  the  atrophic  process  and  consequent  normal  amenor- 
rhoea  which  at  this  time  should  take  place.  It  may  be  laid  down  as 
a  general  proposition,  moreover,  that  an  abnormal  menopause,  even 
though  not  hemorrhagic,  is  a  positive  indication  for  thorough  exami- 
nation, both  local  and  general,  with  a  view  to  accurate  and  adequate 
diagnosis..  This  indication  is  strengthened  by  the  frequent  develop- 
ment, during  this  critical  period,  of  malignant  disease  and  mental 
disorder. 

Treatment  of  Uterine  Hemorrhage 

The  foregoing  paragraphs  on  Etiology  and  Diagnosis,  when  consid- 
ered in  their  relations  to  treatment,  should  lead  to  the  following  gen- 
eral statement,   to  which,   however,   numerous  exceptions  will  arise: 

The  treatment  of  uterine  hemorrhage  in  girls  and  young  women  is 
often  that  of  a  systemic  cause;  the  treatment  in  married  women  of 
the  childbearing  age  is  usually  that  of  endometritis,  benign  tumors, 
or  displacements;  the  treatment  of  the  menorrhagia  of  spinsters  is 
commonly  that  of  benign  tumors;  and  of  women  between  the  ages  of 
forty  and  fifty  years,  often  that  of  malignant  growths  or  myomata; 
the  treatment  during  senility  is  often  that  of  malignant  disease. 

Therapeutic  measures  most  frequently  employed  comprise: 

1.  Systemic  treatment. 

2.  Local  treatment. 

3.  Sm-gical  operations. 

1.  Systemic  Treatment. — Rest  in  bed  during  the  most  excessive 
part  of  the  flow,  freedom  from  mental  disturbance,  bathing,  passi\-e 
exercise,  the  use  of  nutritious,  non-irritating  food,  the  avoidance  of 
stimulants,  and  residence  in  a  temperate  or  cold  climate  at  or  near 
the  sea-level  are  the  principal  hygienic  measures.  Drugs,  such  as 
calcium  chloride,  stypticin,  salines,  ergot,  digitalis,  cinnamon,  nuclein, 
and  hydrastis  canadensis,  may  be  selected  according  to  special  indica- 
tions. ^^^len  there  is  systemic  haemophilia  an  abundance  of  gelatin 
taken  with  the  food  is  known  to  increase  the  coagulability  of  the  blood. 

H.  J.  Boldt,'  of  Philadelphia,  strongly  indorses  the  use  of  Cotarnine 
Hydrochloride  as  a  remedy  for  uterine  hemorrhage.  He  begins  with 
"1  grain  doses  three  times  a  day  about  one  week  before  the  ex-pected 

»  New  York  Medical  Journal,  February  25,  1905. 


742  DISORDERS   OF  MENSTRUATION  AND  STERILITY 

flow,  and  as  soon  as  the  flow  begins  to  let  the  patient  take  2h  grains 
every  three  hours  to  be  continued  during  the  entire  period.  In  instances 
of  metrorrhagia,  from  2|  to  5  grains  may  be  given  at  intervals  of  from 
two  to  three  hours  until  the  bleeding  is  lessened,  then  the  dose  may  be 
decreased  to  from  1  grain  to  2h  grains.at  intervals  of  three  to  four  hours. 
If  a  quick  result  is  important,  it  is  best  to  give  3  to  5  grains  in  a  10 
per  cent,  solution  subcutaneously  into  the  buttocks,  using  the  customary 
antiseptic  precautions.  Smaller  doses  do  not  often  give  satisfactory 
results.  Because  of  the  disagreeable  taste  of  Cotarnine  Hydrochloride, 
it  is  best  administered  in  the  form  of  dry  capsules,  or  in  tablet  form." 

2.  Local  Treatment. — The  hot-water  vaginal  douche  and  vaginal 
and  uterine  tamponade,  as  described  in  Chapters  IV.  and  XXIV., 
are  the  two  most  satisfactory  means  of  local  treatment.  The  latter 
especially  as  a  temporary  measure,  if  properly  applied,  is  most  effective. 
Intra-uterine  applications  of  adrenalin  have  been  recommended  highly. 
Intra-uterine  injections  of  strong  astringents,  such  as  concentrated 
solutions  of  iodine  and  tincture  of  iron,  are  used  frequently,  and  may 
in  some  cases  be  promptly  effective;  but  the  liability  of  setting  up 
painful  uterine  contractions  and  the  danger  of  invasion  of  the  Fallopian 
tubes  and  of  possible  pelvic  infection,  are  serious  objections  to  their 
general  use. 

3.  Surgical  Operations. — The  operative  treatment  is  usually  not 
directly  that  of  the  mere  symptom,  hemorrhage,  but  rather  of  such 
diseases  as  endometritis,  metritis,  myoma,  cancer,  and  sarcoma.  The 
surgery  of  these  diseases  may  be  found  discussed  in  other  parts  of 
the  book. 

Hypodermodysis  has  been  mentioned  in  the  chapter  on  After-treat- 
ment of  Major  Operations,  and  in  the  chapter  on  Uterine  Myomata. 
In  cases  of  alarming  hemorrhage  the  only  promising  measure  may  be  a 
Direct  Transfusion  of  the  blood,  for  which  the  reader  is  referred  to  the 
^Titings  of  Crile,  Brewer,  Leggett,  Janeway,  Sorese,  and  to  the  ^•aluable 
device  invented  by  Dr.  Arthur  Curtis,^  of  Chicago. 

1  Curtis.  From  the  Memorial  Institute  for  Infectious  Diseases,  the  Journal  of  the  American  Medical 
Association,  Januar\'  7,  1911,  p.  35;  Journal  of  the  American  Medical  Association,  October  23,  1911; 
Su^ge^^^  Gvnecologj",  and  Obstetrics,  October,  1912;  Brewer  and  Leggett,  Surgery,  Gynecology,  and 
Obstetrics,  "1909,  ix,  293;  Janeway,  Annals  of  Surgerj%  1911,  liii,  720;  Sorese,  New  York  Medical 
Journal,  1911,  xciii,  623. 


CHAPTER   XLVII 

DYSMEXORRIICEA  AND  PERIODIC  INTERMENSTRUAL 

PAIN 

DYSMENORRHEA 
Definition  and  Classification 

Dysmenorrhcea  is  painful  menstruation.  This  definition  does 
not  include  the  slight  heaviness  in  the  loins,  the  general  malaise,  the 
vague  sense  of  discomfort,  and  the  irritability  that  go  to  make  up 
"the  unwell  feeling"  of  healthy  women  during  the  menstrual  week. 
The  slight  "unwell  symptoms,"  so-called,  although  sometimes  absent 
in  normal  cases,  are  not  evidences  of  disease,  and  may  therefore  be 
disregarded. 

The  numerous  attempts  to  classify  dysmenorrhcea  ha\-e  led  to  the 
use  of  a  complicated  and  abundant  nomenclature,  of  which  each  term 
is  taken  to  designate  a  particular  variety  of  painful  menstruation. 
Dysmenorrhcea  accordingly  has  been  characterized  variously  as  tubal, 
ovarian,  membranous,  inflammatory,  congestive,  neuralgic,  spasmodic, 
intermenstrual,  mechanical,  or  constitutional.  Such  designations, 
although  useful  for  purposes  of  description,  are,  when  considered  from 
the  standpoint  of  classification,  wholly  misleading.  The  morbid  con- 
ditions associated  with  painful  menstruation  are  to  a  considerable 
extent  common  to  most  of  the  so-called  varieties.  For  example,  dys- 
menorrhcea of  inflammatory  causation  might  originate  in  the  ovary, 
tube,  or  uterus.  It  necessarily  would  be  associated  with  congestion,  it 
might  take  place  in  the  intermenstrual  period,  or  might  be  aggravated 
by  causes  of  a  mechanical  or  constitutional  nature.  Almost  any  one 
of  the  above  names,  therefore,  might  with  equal  propriety  be  applied 
to  designate  this  so-called  variety.  The  other  terms  proposed  to 
designate  special  varieties  are  subject  to  similar  criticism.  Further- 
more, the  difficulty — not  to  say  impossibility — of  making  in  the  present 
state  of  our  knowledge  a  scientific  or  practical  classification  of  dysmen- 
orrhcea will  become  even  more  apparent  from  what  follows. 

Clinical  History  and  Diagnosis  of  Dysmenorrhcea 

Degrees  of  Pain. — Pain  associated  with  menstruation  varies  in  the 
widest  limits  from  the  general  malaise  of  the  "unwell  week"  to  the  most 
intense  agony.  In  many  cases  the  pain  is  associated  with  definite 
lesions,  and  disappears  upon  the  cure  of  those  lesions.  In  other  cases 
the  suffering  is  wholly  out  of  proportion  to  the  associated  disease — that 
is,  a  woman  presenting  the  most  exaggerated  evidence  of  pain  may 

(743j 


744  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

upon  careful  examination  disclose  little  or  no  disease  to  account  for  it; 
on  the  other  hand,  extensive  disease  may  exist  and  yet  give  rise  to  little 
or  no  dysmenorrhoea. 

Character  of  Pain. — It  is  usual  in  the  taking  of  histories  of  gyneco- 
logical practice  to  note  the  character  of  the  pains,  and  to  designate 
them  by  such  words  as  distinct,  sharp,  dull,  heavy,  radiating,  dragging, 
bearing-down,  and  labor-like.  The  maximum  pain  may  be  in  the 
back,  loins,  or  pelvis;  it  may  be  constant,  intermittent,  or  remittent; 
it  may  come  on  or  be  most  intense  before  or  during  menstruation;  it 
may  cease  or  may  increase  with  the  establishment  of  the  flow;  it  may 
continue  only  during  the  first  day  or  two,  or  with  varying  degrees  of 
intensity  may  outlast  the  period. 

Unfortunately,  the  conditions  that  determine  the  variation  in  the 
degree  and  character  of  the  pain  are,  for  the  most  part,  not  very  defi- 
nitely known.  So  far,  however,  as  the  conditions  are  known  and  have 
a  practical  clinical  value  they  will  be  considered  later. 

The  following  fourfold  statement  relative  to  the  phenomena  of 
normal  menstruation,  if  read  in  connection  with  Chapter  I.,  will  per- 
haps help  the  student  to  understand  the  variations  of  dysmenorrhoea  i^ 
"  1.  There  is,  in  normal  menstruation,  a  general  premenstrual  and 
menstrual  congestion  of  the  pelvic  organs. 

2.  Ovulation  is  associated  usually  with  menstruation,  but  is  not  an 
essential  factor  of  it. 

3.  There  are  slight  premenstrual  enlargement  and  softening  of  the 
uterus  associated  with  congestion  and  swelling  of  the  mucosa,  reach- 
ing their  maximum,  according  to  Herman,  on  the  fourth  day  of  the 
flow,  and  continuing  for  a  short  time  after  the  bleeding  stops. 

4.  The  menstrual  fluid  is  composed  chiefly  of  blood,  but  with  ad- 
mixture of  cast-off  epithelial  cells  and  lymph-corpuscles. 

Painful  menstruation,  in  exceptional  instances,  may  exist  unasso- 
ciated  with  any  demonstrable  lesion.  In  the  vast  majority  of  cases, 
however,  careful  examination  and  close  analysis  will  disclose  either 
a  local  or  a  systemic  cause,  or  both  combined. 

Associated  Lesions. — In  the  absence  of  a  scientific  and  adequate 
classification  one  may  consider  dysmenorrhoea  in  its  relations  with 
certain  associated  lesions;  these  lesions  are  designated  under  two 
heads,  as  follows: 

A.  Local  diseases,  usually  situated  in  the  pelvis. 

B.  General  diseases,  usually  faults  of  nutrition. 

A.  Dysmenorrhcea  associated  with  Local  Diseases 

The  local  diseases  commonly  associated  with  dysmenorrhoea  are: 

1.  Inflammation. 

2.  Tumors. 

3.  Obstruction. 

4.  Malformations. 

'  Webster.     Diseases  of  Women. . 


DYSMENORRHGEA  745 

1.  Inflammation. — Chronic  Endometritis.  The  most  pronounced  tyj^e 
of  (lysmeiiorrhcjea  (Impendent  upon  iiiHainniatioii  is  described  in  Chapter 
XVI.,  and  is  known  as  membranous  dysmenorrhd'a;  it  is  due  to  an 
exfoHative  endometritis,  which  results  in  the  casting  out,  either  com- 
plete or  in  shreds,  of  an  entire  meml;ranous  layer  from  the  uterine 
mucosa.  The  exfoliation  is  consequent  upon  a  i)r()cess  the  nature 
of  which  is  unknown,  which  so  modifies  the  superficial  layer  of  the 
endometrium  that  the  blood,  not  being  able  to  pass  tlirough  it,  accu- 
mulates at  some  point  behind  and  forcibly  strips  up  a  portion  of  it. 
There  is  then  an  effort  of  the  uterus  to  expel  the  partially  detached 
portit)n;  anil  as  this  is  forced  toward  the  external  os  it  strips  ofl*  and 
drags  after  it  the  remaining  undetached  portion.  The  stripping  off 
and  expulsion  through  the  narrow  cervical  canal  of  the  entire  layer 
are  associated  with  very  strong  intermittent  uterine  contractions  and 
consequent  spasmodic  pain  of  the  most  intense  character.  If  the  mem- 
brane is  detached  and  cast  off  in  slireds,  the  pain  will  be  less  severe; 
if  it  is  cast  off  in  minute  particles,  the  pain  may  be  \'ery  slight.  ]\Iem- 
branous  dysmenorrhoea,  therefore,  for  different  individuals  and  at 
different  times  for  the  same  indi\"idual  may,  according  to  the  size  of 
the  exfoliated  masses,  be  very  slight  or  most  intense. 

Projections  into  the  endometrium  of  granulation-tissue,  the  product 
of  chronic  endometritis,  may  stimulate  the  swollen  irritable  uterus  to 
spasmodic  contractions  similar  to  those  of  membranous  dysmenorrhoea, 
though  usually  less  severe.    See  Chapter  XVI. 

Chronic  Metritis. — Dysmenorrhoea  when  associated  with  chronic 
metritis  may  be  attributed  to  the  presence  of  an  abnormal  amount  of 
fibrous  tissue;  this  tissue  is  so  dense  and  unWelding  that  it  prevents 
the  normal  premenstrual  softening  of  the  uterus  and  the  widening  of 
the  uterine  canal,  and  in  this  way,  especially  when  the  organ  is  con- 
gested, may  exert  painful  pressure  on  the  uterine  nerves.  ^Metritis 
does  not  necessarily  cause  dysmenorrhoea.  The  symptom  may  result 
from  the  complications  of  metritis,  such  as  displacement,  fixation,  or 
stenosis  of  the  uterus,  inflammation  of  the  uterine  appendages,  chronic 
cellulitis,  chronic  peritonitis,  or  some  neurosis. 

Chronic  Salpingitis. — Xo  satisfactory  explanation  has  been  given 
of  the  severe  dysmenorrhoea  that  sometimes  accompanies  salpingitis. 
Cases  in  which  the  tube  is  distended  moderately  with  pus  are  usually 
more  painful  than  those  in  which  there  is  great  distension.  ^Moreover, 
severe  salpingitis  may  exist,  and  yet  give  rise  to  no  dysmenorrhoea. 
For  further  information  on  the  subject  the  reader  is  referred  to  Chapters 
XVIII.  and  XIX. 

Chronic  Ovaritis  is  almost  inseparable  from  inflammation  of  other 
pelvic  organs.  Its  influence  therefore  as  a  cause  of  dysmenorrhoea 
cannot  be  estimated  accurately.  Painful  menstruation  associated  with 
ovaritis  is  characterized  often  by  a  period  of  premenstrual  suffering 
variable  in  duration,  by  rather  pronounced  nervous  symptoms,  and 
by  mammary  tenderness.  Ovarian  pain  is  especially  apt  to  radiate 
to  the  thighs  and  nates.    Pain  referred  to  the  ovaries  is  common,  and 


746  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

often  exists  in  the  absence  of  a  demonstrable  lesion  in  the  ovaries. 
Removal  of  the  ovaries  under  such  conditions  seldom  gives  permanent 
relief. 

2.  Tumors. — The  tumors  most  frequently  associated  with  dys- 
menorrhoea  are  uterine  myomata  of  the  intramural,  submucous,  or 
intra-uterine  variety.  These  tumors  may,  especially  during  the  period 
of  menstrual  congestion,  cause  pain  in  the  following  ways: 

1.  An  intra-uterine  or  intramural  tumor  may  stimulate  the  uterus 
to  attempt  its  expulsion  by  painful  uterine  contraction. 

2.  A  tumor  may  by  its  weight  produce  displacement  of  the  uterus 
and  consequent  painful  menstruation. 

3.  A  tumor,  if  it  fills  the  pelvis,  may  produce  pressure-symptoms; 
and  these  symptoms  may,  owing  to  the  menstrual  congestion,  be 
aggravated  during  the  catamenia. 

Displacements  of  the  uterus  as  associated  factors  in  dysmenorrhoea 
are  considered  further  in  Part  V.  In  this  connection  the  reader's 
attention  is  directed  especially  to  the  subject  of  anteflexion  as  laid 
down  in  Chapter  XLIII. 

3.  Obstruction. — Stenosis  within  the  cervical  canal,  and  conse- 
quent obstruction  to  the  outflow  of  blood,  have  held  a  large  place  in 
the  controversial  literature  of  dysmenorrhoea.  The  claimants  for  the 
mechanical  theory,  on  the  one  hand,  sometimes  have  attributed  all, 
or  nearly  all,  painful  menstruation  to  narrowing  of  the  uterine  canal; 
while  their  opponents  not  infrequently  have  denied  altogether  to  this 
cause  any  considerable  place  in  the  causation  of  dysmenorrhoea.  It 
may  be  sufficient,  without  going  over  the  arguments  for  and  against 
the  mechanical  theory  of  dysmenorrhoea,  to  say  that  contraction  of  the 
cervical  canal  has  been  properly  almost  excluded  as  a  direct  mechani- 
cal cause  of  dysmenorrhoea.  The  following  paragraph  will  show,  how- 
ever, that  this  exclusion  does  not  by  any  means  dispose  of  mechanical 
obstruction  as  a  frequent  indirect  cause  of  painful  menstruation. 

Two  forms  of  obstruction  may  be  due  to  anteflexion.  One  is  ob- 
struction in  the  uterine  canal,  due  to  collapse  of  the  uterine  canal 
at  the  point  of  bending;  the  other  is  obstruction  in  the  blood-vessels, 
due  to  collapse  of  the  walls  of  the  vessels  also  at  the  point  of  bending. 
The  obstruction  which  causes  the  dysmenorrhoea  is  commonly  in  the 
blood-vessels,  not  so  commonly  in  the  uterine  canal. 

Some  authorities  deny  that  dysmenorrhoea  when  associated  with 
flexion  is  in  any  sense  due  to  obstruction  either  in  the  uterine  canal 
or  in  the  vessels,  and  attribute  the  pain  wholly  to  the  associated  uterine 
or  extra-uterine  inflammation.  It  is  true  that  inflammation  in  a  sense 
causes  the  pain;  but  it  is  also  true  that  it  causes  the  flexure,  and  that 
the  flexure,  once  formed,  tends  to  keep  up  the  inflammation.  The  two 
together  constitute  what  has  been  called  a  vicious  circle;  the  former 
producing  the  latter,  and  the  latter  reacting  to  aggravate  and  perpetuate 
the  former.  A  fuller  statement  of  the  two  forms  of  obstruction  may 
be  found  in  Chapter  XLIII. 


DYSMENORRHGEA  747 

4.  Malformations. — IMalformations  of  the  pelvic  organs  may  he 
associated  with  dysinciiorrha'a  in  the  foUowing  way:  there  may  he 
atresia  somewhere  in  the  j^enital  tract,  with  consequent  retention  of 
menstrual  fluid,  so  that  during  successive  periods  the  l)lood  accumu- 
lates with  steadily  increasing  and  painful  distension. 

B.  Dysmenorrhcea  associated  with  General  Diseases 

The  strong  surgical  bias  in  gynecological  practice,  emphasized  by 
the  remarkable  results  that  have  been  obtained  by  operative  and 
mechanical  measures,  and  by  the  relative  safety  of  such  measures 
when  aseptically  eni])loyed,  has  led,  during  the  last  generation,  to 
an  undue  estimate  of  the  value  of  surgical  procedures,  and  to  a  cor- 
responding neglect  of  general  therapeutic  requirements.  Accordingly, 
there  has  been  during  the  past  thirty  years  a  strong  movement  along 
surgical  and  mechanical  lines,  and  a  corresponding  disposition  to  dis- 
regard the  claims  of  internal  medicine.  On  the  other  hand,  to  ignore 
extrapelvic  causes  of  pelvic  pain  or  to  disregard  pelvic  causes  of  sys- 
temic disturbances  would  be  manifestly  absurd.  In  either  case  most 
embarrassing  blunders  in  diagnosis  and  treatment  necessarily  would 
follow. 

Many  constitutional  and  systemic  conditions  predispose  to  painful 
menstruation;  they  may  be  associated  with  dysmenorrhcea  with  or 
without  demonstrable  local  lesions.  In  some  cases  in  which  local 
disease  is  not  present,  or,  if  present,  is  not  sufficient  to  account  for 
the  menstrual  pain,  the  dysmenorrhcea  must  be  attributed  chiefly 
or  wholly  to  general  causes.  Among  the  general  disorders  often  asso- 
ciated with  dysmenorrhcea  are  rheumatism,  gout,  ansemia,  chlorosis, 
malaria,  neurasthenia,  and  hysteria.  What  Goodell  aptly  called  the 
intangible,  imponderable,  invisible  pelvic  pains  of  neurotic  women  are 
especially  liable  to  increase  during  menstruation. 

In  one  pronounced  class  of  cases  the  reproductive  organs  may, 
from  lack  of  proper  innervation  and  nutrition,  have  failed  to  mature 
at  the  age  of  puberty,  and  therefore  may  perform  the  menstrual  func- 
tion imperfectly;  the  defect  declares  itself  not  infrequently  in  the  form 
of  an  intensely  painful  effort  to  menstruate — that  is,  a  painful  molimen 
with  little  or  no  flow.  The  lack  of  innervation  and  nutrition  in  such 
cases  is  not  often  confined  to  the  pelvic  organs;  it  is  usually  systemic. 
Dysmenorrhcea  of  this  kind,  therefore,  has  both  a  systemic  and  a  local 
source. 

Among  the  neuroses  most  frequently  associated  with  dysmenor- 
rhcea are  neurasthenia  and  hysteria;  the  one,  characterized  by  exces- 
sive hyperesthesia  and  involving  motor  weakness;  the  other,  charac- 
terized by  loss  of  power  and  coordination  over  automatic  movements 
and  by  an  excessive  responsiveness  to  suggestion.  Either  of  these 
neuroses  may  coexist  with  dysmenorrhcea  in  cases  that  present  no 
local  disease,  or  local  disease  so  slight  that  in  an  otherwise  normal 
woman  it  would  have  little  or  no  recognition. 


748  DISORDERS  OF  MENSTRUATION  AND  STERILITY 


Treatment  of  Dysmenorrhoea 

There  are  two  possible  errors  that  may  be  made  in  connection  with 
treatment.  One  is  that  a  distinct  nervous  or  other  general  disorder 
closely  related  to  the  causation  of  the  pain  may  be  overlooked  or 
neglected;  the  other  is  that  exaggerated  importance  may  be  given  to 
some  insignificant  local  lesion,  that  this  exaggeration  may  result  in 
an  error  of  judgment,  and  that  much  local  treatment  of  what  is  known 
as  the  tinkering  kind  may  be  adopted  or  that  unnecessary  operations 
may  be  performed.  Of  course,  the  opposite  mistake  may  be  made — 
that  is,  unnecessary  general  treatment  may  be  employed  to  the 
exclusion  of  necessary  local  or  surgical  treatment.^  Norman  Kerr,  of 
Chicago,  reports  cases  of  dysmenorrhoea  associated  with  ovaritis  in 
which  relief  was  obtained  by  resection  of  the  uterine  vessels  and 
nerves  as  they  pass  through  the  infundibulopelvic  ligament.^ 

The  treatment  of  dysmenorrhoea,  like  the  cause,  is  either  local  or 
general,  or  both. 

Local  Treatment. — The  term  local  treatment  here  used  is  extended 
beyond  the  usual  meaning,  and  includes  both  non-surgical  and  surgical 
measures.  These  measures  are  described  in  various  chapters  of  this 
book. 

General  Treatment. — The  general  treatment  is  that  of  the  consti- 
tutional and  systemic  conditions  already  outlined  among  the  possible 
causes  of  painful  menstruation.  The  subject  is  almost  coextensive 
with  the  whole  field  of  general  internal  medicine,  and  cannot  there- 
fore adequately  be  discussed  within  the  limits  of  a  gynecological 
treatise. 

PERIODIC   INTERMENSTRUAL   PAIN 

(German,  Mittelschinerz) 

Periodic  pain,  resembling  the  pain  of  obstructive  dysmenorrhoea, 
recurring  regularly  with  each  intermenstrual  period,  and  continuing 
for  a  definite  time,  is  a  condition  that  often  defies  analysis  and  treat- 
ment. All  explanations  of  this  phenomenon  are  more  or  less  specu- 
lative.   The  three  most  rational  theories  are  that  the  pain  is  caused  by: 

Sclerosis  and  contraction  of  the  ovary. 

Salpingitis  profluens. 

Obstruction  in  the  uterine  canal. 
Sclerosis  and  Contraction  of  the  Ovary. — Hyperplastic  thickening 
and  toughening  of  the  superficial  structure  covering  the  Graafian 
follicles  may  offer  such  resistance  to  the  bursting  of  mature  follicles  as 
to  cause  pain.  It  is  urged  that  there  is  no  periodicity  in  the  maturing 
and  bursting  of  the  follicles,  and  that  the  sclerosis  therefore,  while  it 
might  account  for  the  pain,  could  not  account  for  the  periodicity  of  it; 

1  Adaptation  from  W.  S.  Playfair,  in  a  System  of  Gynecology. 

2  niinois  Medical  Journal,  December,  1903. 


PERIODIC  INTERMENSTRUAL   PAIN  74!) 

a  speculative  reply  to  this  ol)jec'ti<)n  would  he  that  oxulation  troni  some 
unexplained  cause,  perhaps  re\ersion  to  a  former  type,  may  in  rare 
instances  preserve  a  regular  periodicity,  and  that  in  such  exceptional 
cases  sclerotic  toughening  would  account  for  the  periodic  intermenstrual 
])ain. 

The  \\Titer  once  removed  a  sclerotic  right  o\ary  and  tube,  with 
entire  relief  to  the  patient,  from  a  most  excruciating  Miticlsrhinerz  that 
had  for  a  long  time  resisted  all  other  treatment.  The  relief,  however, 
continued  only  through  the  two  periods  immediately  following  the 
operation.  The  pain  at  the  time  of  the  third  and  fourth  i)criods 
recurred,  and  was  nearly  as  severe  as  before;  but  since  the  fourth 
period  there  has  been  partial  relief. 

Salpingiiis  Profluens. — In  numerous  instances  intermenstrual  pain 
of  long  standing  has  disapi)eared  permanently  upon  the  remo^•al  of 
leaky  Fallopian  tubes — hydrosalpinx  or  pyosalpinx.  The  periodicity 
of  the  pain  in  cases  of  this  class  is  explained  by  the  assertion  that  a 
certain  definite  number  of  days  after  each  menstruation  would  be 
required  for  the  tube  to  fill  with  secretions,  and  that  being  filled  it 
discharges  its  contents  into  the  uterus  with  regularly  recurring  pains. 
There  is  no  evidence  in  these  cases  to  show  absence  of  cirrhosis  of  the 
ovary,  hence  the  cause  of  the  pain  may  have  been  ovarian  and  not 
tubal. 

There  may  be  ohstruction  in  the  uterine  canal  from  stenosis  or  flexure, 
and  consequent  periodic  accumulations  of  uterine  secretions,  which 
are  regularly  expelled  by  labor  pains. 


CHAPTER  XLVIII 
STERILITY 

Definition  of  Sterility 

Excluding  the  physiological  sterility  of  infancy  and  senility,  one 
may  define  sterility  as  the  inability  of  the  individual  to  produce  off- 
spring. In  a  broad  sense  a  woman  is  sterile  who  cannot  become  preg- 
nant, or,  if  pregnant,  cannot  produce  a  viable  child.  A  man  is  sterile 
who  cannot  produce  semen  that  w^ill  fertilize  an  ovum.  In  a  narrow 
sense,  a  woman  who  can  conceive  and  imbed  the  ovum  in  the  endome- 
trium should  not,  if  the  ovum  then  dies  and  is  cast  off,  be  classed  as 
sterile.  The  condition,  strictly  speaking,  would  be  not  one  of  sterility 
but  of  abortion.  From  the  clinical  standpoint,  however,  such  early 
abortion  is  not  easily  separable  from  sterility,  for  habitual  abortion 
may  occur  very  early  in  pregnancy — so  early  that  the  pregnancy  could 
not  have  been  recognized.  Sterility  in  the  male,  except  as  it  may 
have  a  gynecological  significance  in  diagnosis  or  prognosis,  will  not 
be  discussed. 

Statistics  of  Sterility 

Pathological  sterility,  as  distinguished  from  the  physiological  sterility 
of  infancy  and  senility,  is  confined  properly  to  the  years  between  the 
end  of  puberty  and  the  beginning  of  the  menopause — that  is,  to  the 
period  of  maturity;  in  the  majority  of  cases  the  limits  are  even  more 
confined,  for  the  capacity  to  bear  children  is  seldom  fully  developed 
until  three  or  four  years  after  puberty,  and  it  generally  ceases  some 
years  before  the  menopause.  Failure  to  bear  children  therefore  in  the 
early  years  of  maturity  or  in  the  late  years  of  the  menopause,  even 
though  it  might  indicate  lateness  in  the  development  of  sexual  vigor 
or  premature  decadence,  should  not  be  considered  pathological,  and 
for  this  reason  it  should  not  enter  into  the  statistics. 

It  is  said  that  10  to  12  per  cent,  of  all  marriages  are  sterile;  this 
however,  is  not  an  index  to  the  frequency  of  female  sterility.  One 
must  also  reckon  with  the  fact  of  male  sterility.  The  proportion  of 
cases  in  which  the  fault  is  in  the  male  has  never  been  the  subject  of 
thorough  investigation,  but  the  estimates  range  from  7  to  40  per  cent. 
The  percentage  is  undoubtedly  very  large,  and  has  added  greatly  to 
the  popular  estimate  of  female  sterility. 

Classification  of  Sterility 

The  varieties  of  sterility,  according  to  the  causes  or  associated  con- 
ditions, have  been  designated  as  follows: 

(750) 


STERILITY  751 

1.  Complete  or  absolute  sterility. 

2.  Incomplete  or  eontinf:;ent  sterility. 

Some  authors  have  made  a  further  classification  of  congenital  and 
acquired  sterility;  these  varieties,  however,  are  only  subdivisions  of 
complete  and  contin<i;ent  sterility,  and  should  therefore  be  considered 
with  them. 

1.  Absolute  or  Complete  Sterility. — Sterility  is  absolute  when  due 
to  congenital  defects,  or  disease,  or  surgical  operations  that  render 
the  generative  organs  permanently  incapable  of  performing  their 
reproducti\e  functions.  The  organs  may  be  congenitally  defective  or 
absent,  or  may  be  impotent  from  disease,  or  may  have  been  removed 
by  surgery. 

2.  Relative  or  Partial  Sterility. — Sterility  is  relative  or  partial  when, 
on  account  of  some  defect  in  development  or  nutrition,  the  functions 
of  the  reproductive  organs  are  performed  inadequately.  The  condi- 
tion may  be  only  temporary,  and  may  disappear  upon  improvement 
of  the  general  health  or  upon  removal  of  some  obstruction  or  disease 
in  the  genital  tract.  To  this  class  belong  cases  of  pregnancy  occurring 
after  years  of  sterile  marriage.  Some  observers  designate  as  relative 
only  that  ^'ariety  in  which,  on  account  of  sexual  or  other  defects,  such 
as  martial  or  mental  incompatibility,  a  man  and  woman  are  unable  to 
act  together  in  reproduction.  In  such  cases  each  may  become  fruitful 
immediately  after  a  second  marriage.  The  question  then  would  be, 
not  whether  the  individuals  are  positively  sterile,  but  rather,  what  is 
the  explanation  of  the  sterile  union  between  them.  Investigation 
would  show  usually  that  the  failure  was  due  rather  to  anatomical  or 
physiological  defects  than  to  mental  incompatibility.  Moreo^'er,  the 
ovum  of  a  sexually  defective  woman,  although  not  impregnable  by  a 
defective  man,  might,  when  brought  in  contact  with  the  semen  of  a 
normal  man,  readily  become  fertilized;  and  vice  versa,  the  semen  of 
a  defective  man  might  fertilize  the  ovum  of  a  normal  woman. 

Etiology  of  Sterility 

A  knowledge  of  the  mechanism  of  conception  is  essential  to  an 
appreciation  of  the  causes  of  sterility.  A  large  portion  of  the  cortical 
substance  of  the  ovary  is  occupied  by  Graafian  follicles  in  all  periods 
of  growth;  each  follicle  contains  a  fluid,  called  liquor  folliculi,  and 
the  ovum.  As  the  follicle  and  its  contained  ovum  mature  the  follicle 
gradually  becomes  distended  with  the  fluid,  appears  beneath  the  sur- 
face, ruptures,  and  discharges  its  contents.  The  ovum  is  now  washed 
out  into  the  pehic  cavity,  and  under  normal  conditions  reaches  the 
Fallopian  tube  and  passes  along  the  tube  toward  the  uterus.  If  at 
this  time,  under  normal  conditions,  coitus  takes  place,  and  seminal 
fluid  containing  virile  spermatozoa  is  deposited  in  the  upper  part  of 
the  vagina,  the  spermatozoa,  of  their  own  power  of  movement,  enter 
the  endometrium  and  work  their  way  upward  along  the  genital  tract 
toward  the  descending  ovum.     The  exact  meeting-place  of  the  two 


752  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

organisms  is  not  known.  There  is  strong  reason  to  infer  that  it  is  in  the 
Fallopian  tube,  perhaps  at  the  abdominal  end,  and  that  the  persistent 
and  virile  spermatozoa  may  consume  several  days  in  traversing  the  long 
distance;  they  have  been  observed  at  the  abdominal  end  of  the  tube 
as  late  as  five  weeks  after  the  last  sexual  intercourse. 

There  are  two  necessary  conditions  for  normal  conception:  one, 
that  the  ovum  as  it  passes  down  the  genital  tract  shall  meet  the  sper- 
matozoa, and  by  them  become  fertilized;  the  other,  that  the  fertilized 
ovum  shall  find  in  the  endometrium  a  place  favorable  to  further 
development,  and  there  become  imbedded.  If  by  reason  of  any  defect, 
general  or  local,  either  one  of  these  conditions  be  absent,  conception  is 
impossible.  The  ovum,  failing  to  reach  the  tube,  may  be  destroyed 
in  the  peritoneal  cavity;  or,  having  reached  it,  may  pass  down  the 
genital  tract  and  fail  to  be  fertilized.  The  spermatozoa  may  not  be 
sufficiently  virile  to  find  their  way  upward  from  the  vagina;  or,  if 
they  reach  the  ovum,  they  may  not  be  able  to  fertilize  it.  The  two 
organisms  may  succumb  to  hostile  environment  or  to  some  anatomical 
defect.  As  indicated  in  the  foregoing,  a  sterile  marriage  may  result 
from: 

1.  Absence  of  virile  spermatozoa. 

2.  Faulty  general  nutrition  in  the  woman. 

3.  Defective  reproductive  organs  in  the  woman. 

4.  Indeterminate  causes. 

1.  Absence  of  Virile  Spermatozoa 

Old  age,  wasting  diseases,  mumps,  congenital  defects,  and  venereal 
diseases  (especially  gonorrhoea)  may  incapacitate  the  man  to  produce 
virile  spermatozoa  or  may  destroy  entirely  the  procreative  power.  Many 
a  woman  has  suffered  useless — not  to  say  injurious — treatment  for 
supposed  sterility  when  the  fault  was  entirely  with  the  husband.  An 
examination  of  the  husband's  reproductive  organs,  including  micro- 
scopical examination  of  the  semen,  may  disclose  orchitis,  stricture  of 
the  urethra,  hypospadias,  or  some  other  defect  that  may  account 
adequately  for  the  sterile  marriage.  A  careful  inquiry  should  be  made 
also  into  the  man's  general  condition.  Tuberculosis  and  syphilis  are 
not  infrequent  causes  of  sterility. 

2.  Faulty  General  Nutrition  in  the  Woman 

Chronic  wasting  diseases  and  such  nutritional  disturbances  as 
chlorosis  and  ansemia,  and,  above  all,  the  accumulation  of  fat,  espe- 
cially the  peculiar  adiposity  of  ansemic  women,  due  to  faulty  metabol- 
ism, but  giving  the  false  appearance  of  plethora,  may  lead  to  sterility. 
Enteric  fever,  scarlatina,  cholera,  variola,  diabetes,  and  nephritis  are 
among  the  diseases  frequently  associated  with  sterility.  Premature 
menopause — that  is,  permanent  atrophy  of  the  reproductive  organs 
and  consequent  sterility — may  result  from  acute  infectious  disease. 
See  Non-puerperal  Atrophy. 


STERILITY  753 

3.  Defective  Reproductive  Organs  in  the  Woman 

Defects  in  the  reproductive  organs,  both  congenital  and  acquired, 
according  to  their  nature,  may  give  rise  to  the  two  varieties  of  sterility 
designated  as  complete  and  incomplete. 

Congenital  Defects  in  flic  Reproductive  Organs  Causing  Complete  or 

Absolute  Sterility 

1.  Al)sencc  of  the  ovaries,  Fallopian  tubes,  or  uterus. 

2.  Rudimentary  ovaries,  Fallopian  tubes,  or  uterus. 

3.  Ino])erable  atresia  in  the  genital  tract. 

Congenital  Defects  in  the  Reproductive  Organs  Causing  Incomplete 
or  Contingent  Sterility 

1.  Immaturity  or  innutrition  of  the  ovaries.  Fallopian  tubes,  or 
uterus. 

2.  Stenosis  or  atresia  in  the  genital  tract,  as  in  the  cervix  uteri, 
vagina,  or  vulva;  infantile  vulva;  abnormal  backward  location  of 
the  vulva. 

3.  Opening  of  the  vagina  into  the  bladder  or  rectum,  or  double 
vagina,  preventing  coition. 

4.  Displacements,  especially  flexures. 

5.  Elongation,  shortening,  or  conical  shape,  and  other  irregular 
developments  of  the  cervix  uteri. 

G.  Lengthening  of  one  lip  of  the  cervix  uteri,  so  as  to  form  a  flap 
over  the  os  uteri  externum. 

7.  Imperforate  hymen  or  cribriform  hymen,  transverse  vaginal 
septum. 

8.  Excessive  convolutions  or  increased  length  of  the  Fallopian 
tubes. 

9.  Double  uterus. 
10.  Gynandry. 

Discussion  of  Congenital  Causes. — For  a  more  extended  descrip- 
tion of  congenital  defects  the  student  is  referred  to  the  Chapters  on 
Congenital  Malformations  and  GjTiatresia. 

A  rudimentary  condition  or  absence  of  the  ovary  may  coexist  with 
a  well-developed  uterus,  and  vice  versa;  either  combination  is  a  cause 
of  complete  sterility.  Absence  of  one  ovary,  if  the  other  is  normal  or 
approximately  normal,  is  not  necessarily  a  cause  of  sterility. 

Septate  or  double  vagina,  with  the  septum  so  disposed  as  to  divide 
the  vagina  into  unequal  parts,  may  permit  impregnation  if  the  larger 
part  is  capable  of  coition.  The  smaller  part  may  serve  only  for  men- 
struation. One  side  of  a  double  uterus  adequately  developed  maj^ 
receive  the  impregnated  ovum  and  carry  it  to  maturity 

Absence  or  impermeability  of  both  Fallopian  tubes,  unless  they  can 
be  opened  surgically,  causes  complete  or  absolute  sterility;  this  defect, 
46 


754  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

however,  is  associated  usually  with  absent  or  rudimentary  uterus. 
Unicorn  uterus  permits  normal  pregnancy,  uterogestation,  and  partu- 
rition. Immaturity  and  innutrition  of  the  ovaries,  rendering  them 
incapable  of  producing  mature  ova,  are  associated  generally  with  some 
defect  in  the  general  systemic  development.  Rare  instances  have  been 
reported  in  which  the  reproductive  organs,  seemingly  undeveloped  at 
the  age  of  puberty,  have  later  developed  and  become  fruitful. 

Acquired  Defects  in  the  Reproductive  Organs  Causing  ComjAete 
or  Absolute  Sterility 

1.  Surgical  removal  of  the  uterus,  Fallopian  tubes,  or  ovaries. 

2.  Permanent  atrophy  of  the  uterus  or  ovaries. 

3.  Permanent  and  incurable  occlusion  of  the  Fallopian  tubes  or 
uterus. 

4.  Complete  destruction  from  disease  of  the  functionating  part 
(cortical  substance)  of  the  ovary  and  microcystic  degeneration  of 
the  ovary. 

Acquired  Defects  in  the  Reproductiw  Organs  Causing  Incomplete 
or  Contingent  Sterility 

The  acquired  defects  that  may  produce  incomplete  sterility  are  so 
numerous  and  varied,  so  interactive  and  complicated,  that  they  some- 
times defy  analysis;  they  may  be  designated  generally  as  follows: 

1.  Inflammation  in  the  genital  tract  and  its  results,  such  as  dis- 
placements, adhesions,  pathological  secretions,  stenosis,  atresia,  kinking 
of  the  Fallopian  tubes,  atresia  of  the  cervix  uteri  or  vagina,  tubercu- 
losis and  s}T)hilis  of  the  genital  tract,  hypertrophy  and  hyperplasia, 
atrophic  changes,  microcystic  degenerations  of  the  ovaries,  and  me- 
chanical conditions. 

2.  Tumors  of  the  generative  organs,  and  the  organic  and  mechanical 
changes  that  the  tumors  produce. 

.3.  Faulty  innervation  and  innutrition  of  the  organs  of  reproduction. 
Vaginismus  and  pruritus  vulvse  are  possible  examples. 

Discussion  of  Acquired  Sterility. — Surgical  Operations. — The  surgi- 
cal removal  of  one  ovary  or  Fallopian  tube  does  not  cause  sterility; 
if  both  are  removed,  sterility,  except  possibly  in  rare  cases  of  a  third 
ovary,  is  absolute;  if  a  small  part  of  one  ovary  remains,  pregnancy  may 
occur.  The  removal  of  both  tubes  would  not  necessarily  cause  sterility. 
Pregnancy  has  followed  the  removal  of  both  tubes  by  ligature  placed 
close  to  the  uterus;  in  these  cases  the  ligatured  stump  having  sloughed 
off,  the  uterine  end  of  the  tube  remained  sufficiently  open  to  transmit 
the  ovum.  Excision  of  the  uterine  ends  of  the  tubes  and  union  of  the 
peritoneal  surfaces  over  the  wounds  in  both  uterine  cornua  would  cause 
absolute  sterility.  Pregnancy  may  occur  in  a  uterus  of  which  a  part 
has  been  removed,  especially  the  cervical  part.  Even  considerable 
portions  of  the  wall  of  the  corpus,  as  in  myomectomy,  may  be  sacrificed 


STERILITY  755 

without  causing-  absolute  stt'rilit\-.  Tlicre  is  a  recognized  persistence 
in  the  ovaries,  tubes,  and  uterus  that  soniotimes  enahlos  them,  even 
though  mutihited  and  mostly  destroyed,  to  j)erform  the  reproduc- 
tive functions.  Numerous  conservative  operations,  therefore,  designed 
to  })reserve  in  wliole  or  in  i)art  the  uterus  and  its  ai)pen(higes,  have  been 
substituted  for  tlie  rachcal  operation  of  remo\al.  See  ^Myomectomy, 
Salpingostomatomy,  Resection  of  the  Ovary,  and  Vaginal  Incision  and 
1  )rainage. 

Inflammatory  Disorders  of  the  uterus,  Fallopian  tubes,  or  ovaries  are 
associated  with  a  great  majority  of  cases  of  acquired  sterility.  Ovaritis 
may  result  in  atrophy  or  other  organic  changes  that  will  render  the 
ovary  sterile  or  incapable  of  producing  mature  ova.  Atrophy  of  the 
ovaries,  general  or  acquired,  may  or  may  not  be  associated  with  atrophy 
of  the  uterus. 

Salpingitis  may  set  uj)  thickening,  adhesions,  kinking,  stenosis,  or 
atresia  of  the  tube,  and  in  this  way  may  impede  the  ovum  in  its  passage 
to  the  uterus  or  pathological  secretions  may  destroy  it.  Inflammatory 
thickening  of  the  muscular  layer  may  embarrass  the  tube  in  passing 
the  ovum  toward  the  uterus.  Endosalpingitis  may  destroy  the  cilia 
of  the  tubal  epithelium,  so  that  they  cannot  aid  in  the  transmission  of 
the  ovum.  Catarrhal  salpingitis  may  cause  temporary  obstruction 
of  the  tube  from  swelling  of  the  mucosa. 

Endometritis  may  produce  a  pathological  secretion  so  abundant 
and  so  hostile  to  the  impregnated  ovum  as  to  prevent  implantation 
— may  even  destroy  it  and  sw^eep  it  out  of  the  uterus;  or,  if  imbedding 
take  place,  the  ovum  may  be  unable  to  survive  the  hostile  environment. 

Sterility  caused  by  gonorrhoeal  or  s\'philitic  salpingitis  and  endo- 
metritis may  be  relative  or  absolute;  more  frequently  the  latter.  This 
is,  perhaps,  a  wise  provision  of  nature  to  limit  reproduction  by  per- 
sons having  venereal  disease. 

Endocervicitis  produces  a  cervical  plug  of  gelatinous  mucus  that 
mechanically  prevents  the  ingress  of  spermatozoa  to  the  endometrium. 

General  metritis  even  more  than  endometritis  renders  the  uterus 
unfit  for  gestation. 

Exfoliative  endometritis  (membranous  dysmenorrhoea)  generally 
causes  complete  sterility. 

Pelvic  peritonitis  may  cause  obstruction  of  the  tube  by  closure  of 
the  fimbriated  extremity;  or  may  so  draw  it  aside  by  adhesions  that 
for  mechanical  reasons  it  may  fail  to  transmit  the  ovum. 

Parametritis,  although  apt  to  be  associated  with  inflammations 
elsewhere,  in  not  in  itself  a  very  significant  cause  of  sterility. 

A^aginitis  may  produce  a  hyperacid  secretion  that  is  hostile  to  the 
spermatozoa,  and  may  induce  incomplete  sterility  by  cicatricial  stenosis, 
or  by  adhesions  of  the  vaginal  portion  of  the  cervix  to  the  vaginal 
fornix,  or  by  cicatricial  shortening  of  the  vagina.  A'aginitis  and  vuho- 
.  vaginitis  prevent  coition  or  render  it  painful  and  imperfect,  and  are 
therefore  not  infrequent  causes  of  incomplete  sterility. 

Painful  caruncle  of  the  urethra  and  kraurosis  vulvae  are  other  causes 


756  DISORDERS  OF  MENSTRUATION  AND  STERILITY 

of  dyspareunia  and  consequent  incomplete  sterility.  The  presence  of 
urine  in  the  vagina  from  a  vesicovaginal  fistula  may  destroy  sperma- 
tozoa, both  by  its  own  toxins  and  by  the  vaginitis  that  it  would  cause. 

Atrophy  of  the  uterus  may  be  either  concentric  or  excentric;  both 
cause  sterility,  the  former  more  positively  than  the  latter.  See  Atrophy 
of  the  Uterus  in  chapter  on  Amenorrhoea.  Curettage  has  been  followed 
occasionally  by  atrophy  of  the  uterus. 

Tumors  of  the  genital  organs,  by  their  mechanical  effects  or  by 
their  depressing  systemic  influence,  may  induce  sterility;  but  they 
more  commonly  do  so  by  the  inflammatory  or  other  organic  changes 
which  they  set  up.  The  irritating  presence  of  a  uterine  myoma  causing 
endometritis,  and  complete  destruction  of  ovarian  tissue  by  the  pres- 
ence of  an  ovarian  tumor,  are  familiar  examples.  A  case  has  been 
reported  of  a  woman  who  had  given  birth  to  twelve  children,  of  whom 
the  last  was  only  three  months  old  at  the  time  of  the  removal  of  two 
dermoid  ovaries.  This  case  illustrates  the  fact  than  an  ovarian  cyst, 
although  it  may  cause  partial  sterility,  yet,  unless  it  has  destroyed  the 
entire  cortical  substance  of  the  ovary,  does  not  cause  complete  sterility. 
Displacements  a7id  stenosis  of  the  uterus,  especially  flexions,  are 
associated  very  commonly  with  incomplete  sterility.  It  is  highly 
probable  that  these  lesions  cause  sterility  rather  from  associated  en- 
dometritis, salpingitis,  and  perimetritis,  than  from  any  direct  influence 
they  exert  'per  se. 

The  above  statement  is  especially  true  of  pathological  anteflexion 
and  stenosis  of  the  os  uteri  externum.  Spermatozoa  will  pass  through 
very  minute  openings,  but  catarrhal  conditions  above  may  destroy 
them.  In  sounding  the  uterus  for  the  diagnosis  of  atresia  or  stenosis, 
care  should  be  taken  lest  the  sound,  by  catching  in  a  fold  of  cervical 
mucosa,  make  the  canal  appear  imperforate.  It  is  also  important  to 
observe  whether  the  sound  passes  on  by  pushing  aside  an  unrecognized 
valve-like  flap  of  mucosa,  which,  if  left  undisturbed,  might  give  rise 
to  obstruction. 

4.  Indeterminate  Causes 

In  some  cases  the  reproductive  function  has  always  been  absent,  or 
is  suspended  or  lost  without  discoverable  cause.  These  cases  occupy 
an  indefinite  ground  between  absolute  and  contingent  sterility.  To 
say  that  there  is  imperfect  co-ordination  between  important  organs 
involved,  or  that,  owing  to  incompatibility,  the  husband  and  wife 
do  not  act  together  efficiently,  in  nowise  accounts  for  the  failure.  Ab- 
sence of  orgasm  on  the  part  of  the  w^oman  has  been  offered  in  some 
cases  as  an  explanation;  but  there  is  abundant  proof  that,  although  it 
may  have  some  influence,  orgasm  is  not  essential  to  impregnation. 

Diagnosis,  Prognosis,  and  Treatment  of  Sterility 

The  diagnosis,  prognosis,  and  treatment  of  the  symptoms  of  sterility 
necessarily  conform  to  the  various  diseases  that  give  rise  to  it;  and 


STERILITY  757 

arc  set  forth  at  l(Migtli  in  the  prcccdini;'  (•liaj)t(Ts  that  treat  of  those 
(Hseas(>s.    To  those  chapters  the  student  is  referred. 

The  Diagnosis  inchides,  first,  a  careful  examination  of  the  husband. 
If  {\\v  fault,  lies  with  him,  as  it  frequently  does,  the  case  is  not  <.j\'neco- 
lo^ical,  and  should  not  he  made  the  occasion  for  examination  or  treat- 
ment of  the  wife. 

In  examining  the  woman  for  sterility,  it  is  usually  necessary  to  make 
not  only  a  careful  conjoined  examination  of  all  the  reproducti\e  organs, 
hut  as  well  of  the  systemic  condition.  The  local  examination  will 
include  generally  accurate  measurements  with  the  sound  of  the  length 
and  diameter  of  the  uterine  canal. 

Prognosis. — Disease  associated  with  sterility  may  offer  a  favorable 
prognosis  for  anatomical  cure,  and  even  for  the  relief  of  pain  and  other 
annoying  symptoms;  such  a  result,  however,  not  always  is  associated 
with  successful  pregnancy.  The  prognosis  of  sterility,  therefore,  does 
not  necessarily  conform  to  that  of  the  associated  lesions. 

Treatment. — The  treatment  is  that  of  the  associated  lesions,  and 
is  in  no  respect  modified  by  the  fact  that  the  object  of  treatment  is 
impregnation.  The  indication  will  always  be  to  secure  an  open  genital 
tract,  a  normal  state  of  the  reproductive  organs,  and  a  good  systemic 
condition.  The  treatment  of  sterility  by  mechanical  aids  to  pregnancy, 
such  as  the  transfer  of  seminal  fluid  from  the  vagina  to  the  endometrium 
by  injection  immediately  after  intercourse,  has  been  tried;  the  method, 
howe\'er,  is  of  doubtful  value.  See  especially  chapter  on  Pathological 
Anteflexion. 

There  is  considerable  evidence  going  to  show  that  deficient  alkalinity 
of  the  blood  by  rendering  the  secretions  of  the  uterus  less  alkaline  than 
normal  or  acid  may  be  a  cause  of  relatiA'e  sterility  and  that  therefore 
the  free  use  of  alkaline  waters  such  as  Vichy  water  or  of  alkaline  salts 
in  other  form  may  by  rendering  these  secretions  more  normally  alkaline 
favor  survival  of  the  impregnated  ovum. 


CHAPTER   XLIX 

INCONTINENCE  OF  URINE  IN  WOMEN^ 

This  discussion  is  confined  to  the  involuntary  escape  of  urine 
through  the  urethra.  Incontinence  due  to  acquired  urinary  fistula  or  to 
any  congenital  defect  of  the  urinary  tract  will  not  be  considered  here. 
Broadly  speaking,  from  the  point  of  view  of  the  causative  pathology, 
incontinence  has  been  classified  under  two  general  forms,  and  these 
forms  may  occur  singly  or  combined;  they  are: 

1.  Active  incontinence. 

2.  Passive  incontinence. 

1.  Active  incontinence  is  due  either  to  a  hypertonic,  constricted,  or 
distended  state  of  the  bladder,  which  causes  the  urine  to  be  in\-olun- 
tarily  forced  out  through  a  urethra  which  under  ordinary  conditions 
would  have  adequate  sphincteric  power.  The  bladder  acts  to  a  vari- 
able extent  as  a  reservoir,  but  the  sphincter  is  inadequate  to  prevent 
involuntary  escape  of  urine.  Among  the  causes  of  this  form  of  incon- 
tinence are  abnormal  urine,  foreign  bodies,  tuberculosis,  cicatrices, 
tumors  of  the  bladder,  cystitis,  and  other  conditions  which  may  give 
rise  to  such  irritation  and  consequent  contraction  of  the  walls  of  the 
bladder  as  to  overcome  the  sphincteric  power  of  the  urethra  and  to 
force  out  urine.  Overflow  of  an  enormously  distended  bladder  or 
of  a  bladder  very  much  contracted  from  cystitis,  and  having  thick, 
unyielding  walls,  would  be  an  example  of  active  incontinence.  Further 
discussion  of  active  incontinence  does  not  fall  within  the  scope  of  this 
chapter. 

2.  Passive  incontinence  is  due  to  some  sphincteric  defect,  such,  for 
example,  as  traumatism  or  paralysis,  which  deprives  the  neck  of  the 
bladder  and  urethra  of  the  power  of  retention.  Complete  paralysis  of 
the  sphincter  which  causes  urine  to  escape  involuntarily  as  fast  as  it 
enters  the  bladder,  which  is  apt  to  be  of  spinal  origin  and  consequently 
associated  with  paralysis  of  other  parts,  such  as  the  bowel,  bladder, 
and  lower  extremities.  This  form  of  incontinence  also  will  be  excluded 
from  further  discussion. 

The  present  purpose  is  to  consider  the  surgical  treatment  of  another 
and  frequent  variety  of  passive  incontinence  common  in  multiparous 
women,  and  usually  due  to  the  traumatisms  or  other  results  of  partu- 
rition. This  special  form  of  incontinence  is  always  characterized  by  a 
very  appreciable  sagging  away  of  the  urethra  and  neck  of  the  bladder 
from  the  pubes,  and  by  a  dilated  sacculated  appearance  of  the  urethra. 
This  separation  of  the  urethra  from  the  pubes  is  often  caused  by  a 

'  President's  address,  American  Gynecological  Society,  1905,  Journal  American  Medical  Associa- 
tion, June  3,  1905. 

(758) 


METHODS  OF  TREATMENT  759 

cnishiiif,^  or  tearin<;  of  it  from  tlic  symphysis  diiriiif,'  j)arturition.  The 
condition  ordinarily  is  one  of  uretiirocele  and  commonly  is  associated 
with  more  or  less  cystocele,  laceration,  and  relaxation  of  the  perineum, 
and  suhinvolution  of  the  whole  vaf^iiial  outlet.  Tiie  loss  of  urine  is  not 
constant,  hut  is  occasional  or  frequent,  and  occurs  as  a  result  of  couf:;h- 
ing,  sneezin<;,  sudden  change  of  position,  fright,  or  from  some  unassign- 
able, perhaps  neurotic,  condition.  The  bladder  is  neither  distended, 
as  in  cases  of  dribbling  from  overflow  of  urine,  nor  constantly  empty,  as 
in  passive  incontinence  from  paralysis  of  the  sphincter,  but  normally 
holds  more  or  less  urine  which  the  patient  can  pass  or  retain  at  will. 
The  condition  will  be  recognized  as  one  of  frequent  occurrence,  great 
embarrassment  to  the  patient,  and  difficulty  of  cure. 

Methods  of  Treatment 

In  the  literature  up  to  the  present  time,  numerous  operations  and 
procedures  have  been  put  forward  for  the  relief  of  this  form  of  inconti- 
nence; excluding  those  not  especially  pertinent  to  the  subject,  they  are: 

1.  Injection  of  paraffin  into  the  region  of  the  urethra. 

2.  ^Massage  and  electricity. 

3.  Torsion  of  the  urethra,  after  Gersuny. 

4.  Advancing  of  the  urethra,  after  the  method  of  Pawlik,  Hum- 
melfarb,  Albarran,  and  others.^ 

1.  Injection  of  paraffin,  even  if  it  gave  good  results,  which  it  does 
not,  would  be  prohibited  because  of  danger  to  life  from  pulmonary 
embolism. 

2.  Massage  and  electricity,  although  sometimes  temporarily  effec- 
tive, seldom  give  permanent  results. 

3.  Torsion  of  the  urethra,  after  the  method  of  Gersuny,  which 
requires  the  urethra  to  be  dissected  loose  from  its  surroundings  through- 
out its  length,  then  twisted  on  itself  from  180°  to  450°  and  sutured  in 
place,  is  apt  to  overcome  incontinence,  but  is  prohibited  on  account 
of  danger  from  sloughing  of  the  urethra. 

4.  The  advancing  of  the  urethra,  after  Pawlik's  method,  consists 
of  two  lateral  denudations,  one  on  either  side  of  the  urethra,  and  suture 
of  the  denuded  surfaces  in  such  a  manner  as  to  cause  the  urethra  to 
be  stretched  laterally  and  to  be  drawn  up  toward  the  mons  veneris. 
The  operation  is  performed,  according  to  Pawlik,  in  two  parts,  the 
wound  on  one  side  being  allowed  to  unite  firmly  before  that  on  the  other 
side  is  made.  This  operation  is  sound  in  principle — that  is,  advance- 
ment of  the  urethra — but  the  results  too  often  have  not  been  permanent. 
Pawlik  has  proposed  another  operation  in  some  respects  similar  to  the 
one  which  I  shall  describe  later,  but  so  far  as  I  can  learn  he  confines 
the  application  of  it  to  cases  of  congenital  epispadias  and  congenital 
shortening  of  the  urethra.    Hummelfarb  lengthens  the  urethra  by  union 

•  The  significant  literature  on  the  subject  dates  back  but  a  few  years  and  is  rather  meagre.  I  am 
indebted  to  Dr.  Heliodor  Schiller  for  numerous  references  to  articles,  mostly  German,  which  during 
the  past  thirty  years  have  appeared  in  the  periodical  literature,  many  of  which  I  have  consulted. 


Figure  437 


Operation  for  incontinence  of  urine;  showing  denuded  surfaces  and  the  first  two  sutures  in  place,  but 

not  tied. 

(760) 


FinrRK   4^R 


Fir*t  two  sutures  tied  and  meatus  urinarius  drawn  up  to  the  clitoris  and  fastened  there.  The  arrows 
here  show  the  margins  of  the  lateral  parts  of  the  wound  so  rotated  as  to  make  the  sutures  hold  the 
urethra  firrolv  in  its  newly  acquired  elevated  position. 

(761) 


Figure  439 


Last  suture  being  introduced  to  complete  the  operation.  The  previously  sagging  urethra  is  here 
shown  as  extended  and  held  firmly  up  against  the  pubes  in  its  normal  relations.  While  the  lateral 
sutures  are  being  passed  it  is  well  to  have  the  meatus  strongly  pulled  up  toward  the  mons  veneris  by 
means  of  a  tenaculum  hooked  into  it  and  held  in  the  hand  of  an  assistant. 

(762) 


PROPOSED  OPERATION  763 

of  the  lal)ia  I)et\veen  the  meatus  and  the  clitoris  in  order  that  retention 
may  l)o  scciirod  l)y  raisiii<;  the  meatus  al)ove  the  level  of  the  urine  in 
the  bladder.  The  urethra  is  then  expeeted  to  act  on  the  principle  of 
the  spout  of  a  tea-kettle.  This  method,  earlier  described  by  Emmet, 
in  a  majority  of  cases  fails  on  account  of  the  activity  of  the  contracting 
bladder  forcing  out  urine  (active  incontinence)  reiiardless  of  the  level 
of  the  outlet.  Albarran's  operation  consists  of  dissecting  free  the  urethra 
in  making  an  incision  from  the  meatus  to  the  clitoris,  in  forming  two 
flaps,  in  raising  the  urethra  to  the  clitoris,  and  in  suturing  the  flaps 
over  it.  This  operation  is  eft"ecti\e  iniless,  as  sometimes  occurs,  freeing 
of  the  urethra  from  its  surroundings  give  rise  to  sloughing. 

Proposed  Operation 

The  operation  here  described  is  based  on  the  same  principle  as  that 
proposed  by  Albarran — that  is,  ad\ancement  of  the  meatus  urinarius 
to  the  clitoris,  but  this  is  done  without  dissecting  the  urethra  free, 
and,  therefore,  it  obviates  the  danger  of  sloughing  of  the  urethra;  it 
is  performed  as  follows  in  two  steps: 

First  Step. — A  horseshoe-shaped  surface  is  rather  deeply  denuded 
between  the  meatus  urinarius  and  the  chtoris,  and  to  either  side  of  the 
urethra  throughout  the  entire  length  of  it,  as  shown  in  Figure  435. 

Second  Step. — ^The  meatus  is  drawn  up  to  a  point  near  the  clitoris 
and  is  secured  there  by  means  of  two  sutures  (Figures  435  and  43(5) • 
The  lateral  portions  of  the  denuded  surface  are  now  closed,  as  shown 
in  Figure  437.  The  effect  of  the  operation  is  to  replace  and  to  retain 
in  its  functional  relations  the  sagging  displaced  urethra.  It  will  be 
observed  that  the  first  two  sutiu-es  necessarily  stretch  the  urethra 
upward  to  the  region  of  the  clitoris  and  that  the  lateral  sutures  must 
tend  to  hold  it  in  its  new  position.  By  this  means  it  is  proposed  to 
straighten  out  the  urethrocele,  by  longitudinal  traction,  and  by  lateral 
traction  to  collapse  and  to  hold  together  the  dilated  walls  of  the  ure- 
thra, and  thus  to  overcome  the  sacculation  at  the  neck  of  the  bladder 
where  residual  inline  is  apt  to  accumulate  and  give  rise  to  trigonitis, 
cystitis,  and  possible  incontinence. 

In  many  cases  it  will  be  necessary  to  combine  with  the  operation 
some  appropriate  surgical  treatment  for  an  associated  cystocele,  and  in 
nearly  all  cases  to  perform  perineorrhaphy  to  relieve,  also,  relaxation 
of  the  posterior  vaginal  outlet.  In  one  case  I  saw  fit  to  narrow  the 
pouching  urethra  in  order  to  overcome  the  urethral  dilatation. 

I  have  performed  this  operation  many  times  and  in  a  majority  of 
cases  with  gratifying  results.  In  one  case  there  was  so  much  relaxation 
of  the  skin  and  other  soft  parts  in  the  region  of  the  clitoris  that  I  feared 
the  sutured  urethra  might  pull  these  structures  down  to  the  old  mal- 
position instead  of  being  held  up  by  them,  but  so  far  it  remains  well  in 
place.  In  such  a  case  again,  or  in  the  event  of  recurrence  from  such 
a  cause,  however,  I  should  be  disposed  to  make  a  deep  oval  denuda- 
tion over  the  pubes  on  the  mons  veneris  just  above  the  clitoris,  the 


764  INCONTINENCE  OF   URINE  IN   WOMEN 

longer  axis  of  the  oval  being  directed  transversely,  and  to  unite  the 
margins  of  this  wound  by  a  transverse  line  of  union  so  as  to  make  the 
clitoris  a  fixed  point  on  a  sufficiently  high  plane  to  hold  the  urethra 
taut.  For  obvious  reasons,  this  procedure  would  be  preferable  to  the 
removal  of  the  clitoris  and  the  union  of  the  meatus  to  the  parts  thereby 
exposed. 

The  operation  is  so  simple  that  I  have  been  rather  surprised  not  to 
find  myself  precisely  anticipated  in  every  particular,  but  so  far  as  I 
have  been  able  to  learn,  the  operation,  in  some  essential  respects  at 
least,  is  novel.  If  it  should  be  found,  however,  that  I  am  duplicating 
the  work  of  another,  I  desire  to  make  due  acknowledgment  in 
advance. 


INDEX 


Abdomen,    i)iTparation    of,    for    aseptic 

operations,  47 
Abtlominal  drainage,  149 

hysterectomy  for  hivmatometra,  518 

radical,  in  carcinoma  of  uterus,  415 
hysteromyomectomy,      complete,      for 

mj'oma  of  uterus,  386 
hysterorrhaph}^,  678 

for  descent  of  uterus,  646 
technique  of,  680 
incision  in  ovariotomj^,  457 
myomectomy  for  myoma  of  uterus,  378 

drainage  in,  380 
salpingo-oophorectomy,  288 
section,  121 

actual  cautery  in,  127 
adhesions  in,  125 
antipyrine  in,  127 
closure  of  wound  in,  127 
bm'ied  sutm-es  in,  129 
mattress  sutures  in,  130 
Michelle  clips  in,  130 
combined  with  vaginal,  316 
dressings  and  bandages  in,  138 
dusting  powders  in,  138 
incision  in,  123 
exploratory,  123 
median,  through  linea  alba,  123 
intraperitoneal  haemostasis,  127 
Hgatures  in,  127 
operating  tables  in,  121 
for  pelvic  inflammation,  287 
advantages  of,  321 
complications  of,  290 
Dudley's  operation  for,  288 
pressure  forceps  in,  127 
sponge-pressure  in,  127 
sponges  in,  132 

treatment  for,  preparatorj^,  123 
Trendelenburg's  position  in,  121 
substitute  for,  123 
wall,  fat  in,  differentiated  from  ovarian 
cyst,  448 
Abortion,  incomplete,  differentiated  from 
myoma  of  uterus,  369 
in  tubal  pregnancy,  473 
Abscesses,   opening  and  draining  of,   in 
treatment   of  pelvic   inflammations, 
296 
psoas,  differentiated  from  pelvic  cellu- 
litis, 273 


Abscesses,      suburethral,       complicating 
urethritis,  332 
treatment  of,  333 
tubo-ovarian,  260,  440 
Accessory  ovaries,  494 
tubes  and  ostia,  496 
uterus,  497 
Adenoma,  229 

of  Fallopian  tubes,  464 
Adenocarcinoma,  353 

of  uterus,  403 
Adenomatous  cyst  of  ovary,  431 
papillary,  432 
simple,  431 
Adenomyoma  of  Fallopian  tubes,  464 
Adhesions,  440 

teclmique  in,  in  treatment  of  pelvic  in- 
flammations, 292 
Adhesive  peritonitis,  274 
Adnexal  inflammations,  261 

differentiation  of,  264 
Adrenalin  for  hemorrhage,  156 
Alexander's  operation,  672 

for  descent  of  uterus,  646 
Aluminium  acetate,  202 

for  chronic  vulvovaginitis,  183 
Amenorrhcca,  23,  731 
causes  of,  general,  732 

acute  infectious  diseases,  732 
chronic  disorders,  732 
nervous  and  mental  disorders,  732 
local,  731 

endometritis,  731 
metritis,  731 
classification  of,  731 
diagnosis  of,  733 
etiolog}'  of,  731 
pathological,  24 
physiological,  24 
prognosis  of,  733 
symptoms  of,  733 
treatment  of,  734 
local  734 
sj'stemic   734 
Amnion,    formation    of,    in    tubal    preg- 
nancy, 470 
Ampullar  pregnancy,  473 
Ansesthesia  in  conjoined  examination,  64 
Anastomosis,  lateral,  of  ureter,  295 
Androgyny,  510 

Anodynes  for  mycotic  Aiilvovaginitis,  190 
Anovaginal  fistula,  605 
Anteflexion  of  uterus,  687 

(765) 


766 


INDEX 


Anteflexion  of  uterus,  acquired,  690 

cervix  in  labor  after  Dudley's  opera- 
tion for,  709 
classification  of,  690 
complications  of,  691 
congenital,  690 
course  of,  691 
developmental,  690 
diagnosis  of,  693 
etiology  of,  690 
pathological,  689 
pathology  of,  690 
symptoms  of,  691 
urethral,  691 
uterine,  692 

dysmenorrhcea,  693 
endometritis,  693 
steriHty,  693 
vesical,  691 
treatment  of,  694 

complications  of,  695 
by  Dudley's  operation,  700 
by  electricity,  697 
by  forcible  dilatation,  697 
by  local  pelvic  massage,  698 
mechanical  indications  for,  695 
by  pessary,  696 

by    posterior    division    of    cervix 
uteri,  700 
Antelocation  of  uterus,  616 
diagnosis  of,  616 
symptoms  of,  616 
treatment  of,  616 
Anteversion  of  uterus,  687 
diagnosis  of,  688 
etiology  of,  687 
pathology  of,  687 
prognosis  of,  688 
symptoms  of,  687 
treatment  of,  688 
Antiseptic  agents,  35 
heat,  36 
iodine,  36 

liquor  cresolis  comp.,  36 
lysol,  36 

mercuric  bichloride,  36 
soap,  35 

sodium  carbonate,  36 
Antiseptics,  35 
Anus,  atresia  of,  505 

eversion  of,  in  digital  examination,  59 
examination  of,  77 
proctoscope  in,  77 
sigmoidoscope  in,  77 
malformations  of,  503 
Appendicitis  differentiated  from  ovaritis, 
279 
from  pelvic  celluhtis,  272 
from  salpingitis,  265 
Approximation  in  trachelorrhaphy,  563 
Argyrol  for  vulvovaginitis,  182 
Arsenic,  373 

Arteriosclerosis,  chronic  metritis  and,  253 
differentiated  from  carcinoma  of  uterus, 

411 
of  uterus,  411 


Ascent  of  uterus,  615 
diagnosis  of,  616 
symptoms  of,  616 
treatment  of,  616 
Ascites  differentiated  from  ovarian  cvst. 

454 
Asepsis  in  examinations,  41 
of  hands,  42 
of  instruments,  42 
in  minor  manipulations,  41 
of  patient,  41 
Aseptic  conscience,  34 

operations,  clothing  in,  45 

preparations  for,  of  abdomen,  47 
of  operator  and  assistants,  4j 
of  patient,  46 

bowel  distention,  46 
cathartics  in,  46 
enemata  in,  47 
of  vagina,  47 
protection  for  feet  and  legs,  49 
,    surgical  precautions,  48 

technique,  34 
Atresia  of  anus,  505 
congenital,  506 

in  genital  tract,  a  cause  of  sterility,  753 
at  OS  internum,  514 
of  urethra,  505 
of  vagina,  505 

inflammatory,  503 
of  vulva,  superficial,  506 
Atrophic  cellulitis,  chi'onic,  273 
metritis,  251 

non-puerperal,  252 
puerperal,  251 


B 


Bacillus  coli  communis,  34,  334 

tuberculosis,  34,  334,  340 
Barrett's    operation    for    retroflexion    of 

uterus,  672 
Bartholin,  glands  of,  192 

cyst  of,  differentiated  from  myoma 
of  round  ligament,  465 
Benzoated    oxide    of    zinc    for    mycotic 

vulvovaginitis,  190 
Bichloride  of  mercury  for  chronic  vulvo- 
vaginitis, 182 
Bicornate  uterus,  497 
Biers'  cupping  treatment,  97 
Bismuth  poisoning,  182 
Bladder,  care  of,  after  abdominal  opera- 
tions, 154 
curettage  of,  in  treatment  of  cystitis, 

347 
distended,  differentiated  from  ovarian 

cyst,  448 
distention  of,  in  digital  examination,  58 
diverticulum,  ureterocystostomy,  295 
emptying  of,  to  prevent  postoperative 

cystitis,  342 
hernia  of,  632 

stone  in,  in  vesicovaginal  fistula,  577 
tumors  of,  468 


INDEX 


Bhuldor,  tumors  of,  diagnosis  of,  4G8 
Blast 0(k'iin,  A'.Mi 
Blood  vessels,  infection  by,  172 
Btxifiics  in  dilatation  of  uterus,  114 
Bovee  on  shortening  of  uterosacral  liga- 
ments, 078 
liowels,  car(>  of,  after  abdominal  opera- 
tions, lo.'i 
obstruction  of,  after  abdominal  opera- 
tions, 101 
causes  of,  101 
diagnosis  of,  101 
l)n)gnosis  of,  101 
treatment  of,  102 
Brandt's  method  in  retroflexion  of  uterus, 

tint) 
Brickner  on  Dudley's  operation  for  ante- 
flexion of  uterus,  705 
Broad  ligament,  cysts  of,  438 

end-to-end  approximation  of,  034 

advantages  of,  400 
lipoma  of,  405 
myoma  of,  405 
tumors  of,  405 
Byrne  on  ignihysterectomj',  418 


Cachexia  in  carcinoma  of  uterus,  406 

Calcium  chloride,  156,  373 

Calomel,  202,  238 

Capillary  drainage,  140 

Capsule  of  Bowanan,  488 

Carbolic  acid  for  mycotic  vulvovaginitis 

190 
Carbonate,     sodium,     as    an    antiseptic 

agent,  30 
Carcinoma  of  cervix  uteri,  diagnosis  of, 
400 
differentiated  from  laceration,  558 
of  corpus  uteri,  diagnosis  of,  407 
of  Fallopian  tubes,  464 
of  ovary,  427 
of  round  ligament,  466 
of  urethra,  467 
of  uterus,  403 

adenocarcinoma,  403 
advanced,  407 
course  of,  404 
cylindrical-cell,  403 
diagnosis  of,  400 

clinical  history  in,  400 
differential,  409 

from  arteriosclerosis,  411 

from  chronic  endocervicitis,  222 

metritis,  410 
from  endocervicitis,  409 
from  endometritis,  410 
from  endothelioma,  411 
from  h^Tiertrophy  of  cervix,  409 
from  ichthyosis  uteri,  410 
from  laceration  of  cervix,  411 
from  myoma,  308,  409 
from  ovarian  cysts,  "451 
from  retained  placenta,  409 


Carcinoma  of  uterus,  diagnosis  of,  differ- 
ential, from  sarcoma,  4(J9 
from  syphilis,  410 
from  tuberculosis,  410 
extension  of,  408 
to  bladder,  408 
to  glands,  408 
by  metastasis,  408 
to  parametria,  408 
to  rectum,  408 
to  vagina,  408 
physical  signs  in,  400 
recurrence  of,  after  removal,  408 
epithelioma,  403 
etiology  of,  403 
gland,  403 
pathology  of,  403 
I)avement-cell,  403 
prognosis  of,  411 
squamous,  403 
symptoms  of,  404 
cachexia,  400 
hemorrhage,  405 
pain,  405 

uterine  discharge,  405 
visceral  disorders,  405 
treatment  of,  412 
general,  421 
hysterectomy  in,  413 
ignihysterectomy,  417 
mortality  of,  419 
paravaginal,  413 
radical  abdominal,  415 
recurrence  after,  420 
operation  of  election  in,  420 
palliative,  421 
radium  in,  421 
x-ray  in,  421 
of  vagina,  357 

treatment  of,  357 
of  xulvsi,  353 

cylindrical-cell,  353 
diagnosis  of,  354 

positive,  354 
etiology  of,  353 
pathology  of,  353 
pavement-cell,  353 
treatment  of,  354 
Caruncle  of  urethra,  406 
a  cause  of  sterility,  755 
differentiated  from  urethritis,  327 
Cases,  hj'pothetical,  51 

record  of,  form  for,  50 
Castor    oil    in    preparation    for    aseptic 

operations,  40 
Catgut,  chromicized,  41 
formalized,  41 
sterilization  of,  40 
Catheter,  permanent,  use  of.  in  cvstitis, 

345 
Catheterization,  342 

in  examination  of  urinary  organs,  80 
of  ulcers,  347 
Cellular  tissue,  208 
Cellulitis,  chronic  atrophic,  273 
pelvic,  208 


768 


INDEX 


Cellulitis,  pelvic,  anatomy  of,  268 
diagnosis  of,  270 
differential,  272 

from  appendicitis,  272 
from  haematocele,  272 
from  ovaritis,  279 
from  peritonitis,  272 
from  psoas  abscess,  273 
from  pyosalpinx,  272 
from  salpingitis,  265 
from  subserous  myoma,  273 
from  tubal  pregnancy,  480 
etiology  of,  288 
pathology  of,  269 
associated,  270 
prognosis  of,  273 
symptoms  of,  270 
treatment  of,  273,  280 
of  Stapfer,  270 
Cervical  myoma  of  uterus,  364 
Cervix  uteri  after  normal  labor,  549 

amputation  of,  for  apparent  hyper- 
trophy, 555 
before  labor,  548 
carcinoma  of,  diagnosis  of,  406 
division  of,  for  anteflexion  of  uterus, 

700 
during  labor,  548 
erosions  of,  220,  556 
foUicular,  558 
granular,  556 
papillary,  220,  556 
simple,  220 
excoriation  of,  556 
glandular  enlargements  of,  220 
cystic,  221 
polypoid,  220 
granulation  of,  556 

coxcomb,  558 
hypertrophic  enlargement  of,  555 
hypertrophy  of,  differentiated  from 

carcinoma  of  uterus,  409 
hysterectomy  of,  for  apparent  hyper- 
trophy, 555 
incision  of,   anterior,   in  myoma  of 

uterus,  377 
in  labor  after  Dudley's  operation  for 

anteflexion  of  uterus,  709 
laceration  of,  anterior,  547 
carcinoma  from,  555 
causes  of,  546 

cicatricial    narrowing    of    uterine 
canal  in,  556 
reflex  irritation  from,  556 
diagnosis  of,  556 
differential,  558 

from  carcinoma,  411,  558 
from      congenital      eversion, 

558 
from  endocervicitis,  558 
directions  and  extent  of,  547 
false  cervix  in,  548,  552 

apparent     hypertrophy     and 

elongation  in,  553 
cystic   degeneration   in,    552, 
556 


Cervix  uteri,   laceration  of,   false  cervix 
in     descent     and     vaginal 
reduplication  in,  549 
subinvolution  in,  549 
prophylaxis  of,  559 
puerperal,  546 
symptoms  of,  555 
treatment  of,  559 

atypical  lacerations,  566 
resection  of  cervix,  566 
trachelorrhaphy  in,  559 
after-treatment,  571 
approximation  in,  563 
denudation  in,  563 
disinfection  in,  562 
hemorrhage  in,  564 
immediate  operation,  559 
preparatory  treatment  of,  560 
removal  of  cicatricial  plug  in, 

563 
results  in,  571 
secondary  operation,  560 
sutures  in,  564 
ulceration  of,  556 
Chancroidal  vulvovaginitis,  191 

treatment  of,  191 
Chloride,     mercuric,     as     an     antiseptic 

agent,  36 
Chorio-epithehoma  of  uterus,  425 
diagnosis  of,  426 
etiology  of,  425 
pathology  of,  425 
prognosis  of,  426 
symptoms  of,  426 
treatment  of,  426 
Chorioma  sarcomatosum,  425 

sjmcytiale,  425 
Chorion,    formation    of,    in    tubal   preg- 
nancy, 470 
Circumcision,  technique  of,  508 
Cirrhotic  metritis,  250 
Clark  on  paravaginal  hysterectomy  for 

carcinoma  of  uterus,  414 
Claudius'  solution,  iodization  by,  40 
Chtoris,  hypertrophy  of,  508 

malformations  of,  508 
Cloaca,  persistent,  506 
Clover's  crutch,  101 

Cocaine  in  treatment  of  vaginismus,  205 
Colica  scortorum,  261 

scortorum,  234 
Colon  bacillus,  a  cause  of  ovaritis,  277 
Colpeurynter  in  treatment  of  inversion 

of  uterus   721 
Colpocystotomy   346 
Condyloma  of  vulva.     See  Papilloma  of 

vulva. 
Condylomata  acuminata,  352 

lata,  352 
Congenital  anteflexion  of  uterus,  690 
atresia,  506 

displacement  of  ovaries,  495 
eversion  differentiated  from  laceration 

of  cervix  uteri   558 
gynatresia,  513 
diagnosis  of,  514 


INDEX 


769 


Congenital   gynatresia,    pathological  re- 
sults of,  513 
prognosis  of,  517 
symptoms  of,  513 
tivatmcnt  of,  517 
malformations,  48(5 
Conjoined  examination,  59 
anu'sthcsia  in   G-4 
rectal  62 
rectovaginal,  64 
roots  of  sciatic  ncrvo  in,  65 
vaginal,  5i) 
with  sound,  65 
Corpus  lutcum  cysts,  431 

uteri,  carcinoma  of,  diagnosis  of,  407 
Corrosive    sublimate    in     treatment     of 
mycotic  vulvovaginitis,  190 
of  prurit  us  vulvic,  202 
Cupping  treatment.  Biers',  97 
Curettage    of    bladder    in    treatment    of 
cystitis,  347 
a  cause  of  sterility,  756 
in  chronic  endometritis,  241 
in  myoma  of  uterus,  375 
of  ulcers,  347 
of  utei'us,  118 
teclinique  of,  120 
Cystitis,  333 
acute,  335 
causes  of,  540 
chronic,  335 
croupous,  337 
diagnosis  of,  338 

differential,  339 
diphtheritic,  337 
etiologv  of,  333 
exfoliative,  337,  345 
exudative,  336 
fibrinous,  337 
fissure,  337 
foreign  body,  337 
gonorrhoeal,  339 
interstitial,  335 
leucoplakia,  337 
non-gonorrhoeal,  340 
pathology  of,  334 
postoperative,  342 
proph3daxis  of,  541 
superficial,  336,  342 
suppurative,  336 
treatment  of,  340 
medical,  342 
prophylactic,  340 
siu"gical,  345 

curettage  of  bladder,  347 
dilatation  of  urethra,  345 
extravesical  operations,  347 
lithotomy,  347 
Uthotrity,  347 
vaginal  cystotomy',  345 
topical,  344 
tubercular,  340 
diagnosis  of,  340 

from  gonorrha?al,  339 
ulcerative,  336 
vesicovaginal  fistula  a  cause  of,  577 

47 


Cystitis  with  granulations,  344 

with  ulcers,  344 

Cystocelc,  526,  (J20 

excision  of,  634 

in  lacerations  of  perineum,  526 
residual  urine  in,  526 
Cystoscopes,  SO,  335 
Casper's,  S3,  S6 
comparison  of,  86 
cyhndrical,  80 
electrical,  83 
Kelly's,  80 
Leiter's,  83,  86 
Nitze,  86,  88 
Cystoscopy    in    examination    of    urinary 

organs,  80 
Cystotomy,  vaginal,  in  cystitis,  345 
Cysts,  adenomatous,  of  ovary,  431 

of    BarthoUn's    glands,    differentiated 
from  myoma  of  round  hgament,  465 
embryonal  vaginal,  356 
of  Fallopian  tubes,  464 
intraligamentous,  of  ovary,  462 
ovarian,  429 

corpus  luteum,  431 
CA'st -adenomata,  431 
papillary,  432 
simple,  431 
dermoid,  434 
complicated,  436 
simple,  435 
diagnosis  of,  444 
adhesions,  445 
clinical  history  in,  444 
conjoined  examination  in,  445 
differential,  447 
from  ascites,  454 
from  dilated  stomach,  448 
from  distended  bladder,  448 
from  fat  in  abdominal  wall,  448 
from  fecal  accumulations,  448 
from  gestation  in  one  horn  of 

bifurcated  uterus,  450 
from  hsematometra,  452 
from  hydatid  cysts,  454 

of  Morgagni,  452 
from  hydramnios,  449 
from  hych'ometra,  452    . 
from  hydronephrosis,  456 
from  metritis,  451 
from  normal  gestation,  449 
from  ovarian  hydrocele,  452 
from  phantom  tumor,  448 
from  physometra,  452 
from  pyometra,  452 
from  renal  tumors,  455 
from  tubal  pregnancy,  450 
from  tympanites,  448 
from  uterine  carcinoma,  451 
from  uterine  myoma,  450 
sarcoma,  451 
inspection  in,  444 
of  maUgnancy,  446 
measurements  in,  445 
palpitation  in,  444 
percussion  in,  444 


770 


INDEX 


Cysts,   ovarian,  exploratory  incision  in, 
456 
follicular,  429 
multilocular,  429 
pathology  of,  429 
prognosis  of,  456 
proliferating,  431 
removal  of,  457 

abdominal  incision  in,  457 
accidents  in,  461 
after-treatment  in,  461 
closure  of  wound  in,  461 
complications  in,  461 

extrusion  of  the  bowel,  461 
foreign  bodies  left  in  abdomen, 

462 
injuries    to    intestines,    ureter, 

and  bladder,  482 
intestinal  obstruction,  462 
rupture  of  cyst  wall,  462 
stripping  of  parietal  peritoneum 
from  abdominal  wall,  462 
dehvery  of  cyst  in,  457 
adhesions  in,  461 
secondary  cysts  in,  461 
semisohd  contents  in,  461 
drainage  in,  461 
emptying  of  cyst  in,  457 
ligature  of  pedicle  in,  481 
secondary  changes  in,  439 
fluid  contents,  439 
infection,  440 
adhesions,  440 
diagnosis  of,  445 
suppuration,  acute,  440 
twisting  of  pedicle,  441 
diagnosis  of,  445 
torsion,  acute,  441 
chronic,  441 
rupture  of,  441 
diagnosis  of,  445 
results  of,  442 
symptoms  of,  442 

facies  ovariana,  443 
unilocular,  429 
parovarian,     429,     436.       See    Cysts, 
ovarian, 
of  broad  ligament,  438 
pathology  of,  436 
pelvic,   differentiated  from  myoma  of 

uterus,  370 
puncturing     of,     in     preparation     for 

trachelorrhaphy,  560 
of  round  ligament,  465 
tubo-ovarian  260,  440 
of  vagina,  356 

diagnosis  of,  differential,  356 
treatment  of,  356 
of  vulva,  355 
sebaceous,  355 


Decidua,   formation  of,   in  tubal  preg- 
nancy, 470 


Deciduoma  adenomatosum,  425 
carcinomatosum,  425 
mahgnum,  425 
diagnosis  of,  426 
etiology  of,  425 
pathology  of,  425  * 
prognosis  of,  426 
symptoms  of,  426 
treatment  of,  426 
sarcomatosum,  425 
Denudation  in  perineorrhaphy,  541 
in  trachelorrhaphy,  563 
of  uterus,  106 

in  vesicovaginal  fistula,  584 
Dermoid  cysts  of  ovary,  434 
comphcated,  436 
simple,  435 
Descent  of  uterus,  616 
course  of,  625 
diagnosis  of,  625 

differential,  625 
enteroptosis  as  complication  of,  646 
etiology  and  mechanism  of,  617 
pathology  of,  623 
prophylaxis  of,  626 
symptoms  of,  625 
treatment  of,  627 
non-surgical,  627 

general  and  local  measures  in, 

627 
hygiene  in,  627 
pessaries  in,  627 
surgical,  628 

abdominal    hysterorrhaphy    in, 

646 
Alexander's  operation  in,  646 
comparison     of     elytrorrhaphy 

and  hysterectomy,  645 
elytrorrhaphy  in,  634 

contraindication  to,  635 
hysterectomy  in,  628 
perineorrhaphy  in,  635 
plastic  operations  in,  630 
Diabetes  a  cause  of  chronic  metritis,  248 
Digital  examination,  57 
conduct  of,  59 

distension  of  bladder  during,  58 
eversion  of  anus  in,  59 
left-hand  method  in,  57 
Dilatation  of  stomach,  acute,  160 
treatment  of,  160 
of  urethra  in  treatment  of  cystitis,  345 
of  uterus,  76,  109 

diverging  instruments  in,  114 

extent  of,  115 

forcible,  dangers  of,  116 

technique  of,  116 
graduated  bougies  in,  114 
tents  in,  109         _ 

with  intra-uterine  medication,  111 
Dilator,  Ellinger's,  Goodell's  modification 

of,  698 
Diphtheritic  vulvovaginitis,  188 

treatment  of,  188 
Displacement  of  ovaries,  congenital,  495 
of  uterus,  607 


/A7;/';.v 


Displacciiicnl  nf  iilcriis,  (Icliiiil  ion  of,  (il  I 
(liafiuosis  dI',  (')12 

tVoiii  iiiyoina,  IW.) 
nial-locatioiis  oi",  (ill,  (il.') 
iiialixisit  ions,  (il2,  (i4cS 
noiiu'iiclal  lire  ot",  (il  1 
syiiiptoins  of,  (il2 
Dist(>n-;ioii  of  hladdcr  in  (lifi;ilal  cxainiiia- 

tiou,  aS 
Dtiilerloin's  cxpcrinicnts,  ISO 
Doiiclu>,  vaginal,  90.    Sec  Vaginal  douche. 
Drainago,  142 

ahiioniinal,    for    pc'lvic    inflaininations, 
2!H) 
((H'hni(Hi(>  in,  29o 
comparison  of  results  of,  142 
evil  results  of,  143 
fecal  fistula,  143 
hernia,  143 

obstruction  of  bowel,  143 
vesical  complications,  143 
forms  of,  14G 
abtlominal,  149 
capillary,  146 
tubular,  146 
vaginal,  150 
gauze  packing  in,  use  of,  147 
peritoneal,  contraindications  for,  145 

indications  for,  146 
to  prevent  infection,  143 
Dress,  even  distribution  of,  164 
freedom  from  traction  in,  166 
relation  of,  to  diseases  of  women,  164 
waist  constriction  in,  165 
Dressings  in  abdominal  section,  138 
Ducts  of  Mueller,  development  of,  490, 

492,  493 
Dudley's    clamp   operation   for   uretero- 
vaginal  fistula,  598 
incision  in  myoma  of  uterus,  377 
method  of  incising  uterus,  118 
operation  for  anteflexion  of  uterus,  700 
cervix  in  labor  after,  709 
for  incontinence  of  m'ine,  763 
reefing  operation  for  salpingo-oophor- 
ectomy,  288 
Dysmenorrhoea,  743 

associated  lesions  of,  744 
with  general  diseases,  747 
with  local  diseases,  744 

chronic  endometritis,  745 
metritis,  745 
ovaritis,  745 
salpingitis,  745 
inflammation,  745 
malformations,  747 
obstruction,  746 
tumors,  74(5 
character  of  pain  in,  744 
classification  of,  743 
clinical  history  of,  743 
definition  of,  743 
degrees  of  pain  in,  743 
diagnosis  of,  743 
due  to  anteflexion  of  uterus,  693 
membranous,  231 


l)\srn(MiorriHr;i,  Ircatmciit  of,  748 
general,  74S 
local,  748 


E 


Eczema  of  vulva,  1!)7 
treatment,  of,  197 
Elephantiasis  of  vulva,  3.50 
diagnosis  of,  3.'')0 

differential,  351 
etiology  of,  3.50 
filaria    sanguinis    honiinis,    exciting 

cause  of,  350 
pathology  of,  350 
treatment  of,  351 
Elytrorrhaphy   in   treatment   of   descent 
of  uterus,  634 
contraindication  to,  635 
Embryology,  486 

of  excretory  organs,  486 
of  generative  organs,  490 
of  genitalia,  486 
Embryonic  structures,   development  of, 

into  organs,  491 
Emmet's  explanation  of  false  cervix,  553 
method  of  treatment  iii  inversion  of 
uterus,  720 
Emphysematous  vaginitis,  196 

treatment  of,  196 
Enchondroma  of  vulva,  356 
Endocervicitis,  chronic,  218 
diagnosis  of,  221 
condition  in,  221 
speculum  examination  in,  221 
etiology  of,  218 
pathology  of,  219 
symptoms  of,  221 
treatment  of,  222 

Schroeder's  operation  in,  223 
differentiated  from  carcinoma  of  uterus, 
409 
from  laceration  of  cervix  uteri,  558 
polypoid,  225 
End,ocystitis,  335 

Endometritis  a  cause  of  amenorrhoea,  731 
chronic,  226 

diagnosis  of,  234 

differential,  234 
dysmenorrhoea  and,  745 
etiology  of,  226 
pathology  of,  226 
prognosis  of,  236 
symptoms  of,  232 
abortion,  233 
pain,  232 

reflex  disorders,  234 
sterility,  233 
systemic  disorders,  234 
treatment  of,  236 
surgical,  241 

curettage  in,  241 
indications  for,  246 
regeneration  of  endometrium 
after,  246 


772 


INDEX 


Endometritis,     chronic,     treatment    of, 
surgical,        curettage      in, 
technique  of,  241 
systemic,  236 
ansemia  in,  237 
constipation  in,  237 
general  hygiene  in,  238 
kidneys  in,  237 

vaccines  and  serum  therapy  in, 
237 
topical,  239 
cystic,  229 
differentiated  froin  carcinoma  of  uterus, 

410 
due  to  anteflexion  of  uterus,  693 
exfoliative,  231,  232 
glandular,  hyperplastic,  229 
hypertrophic,  228 
interstitial  and,  229 
polypoid,  229 
post-abortum,  230 
senile,  231 
Endometrium,     regeneration     of,     after 
curettage,  246 
topical  applications  to,  95 

selection  of  cases  for,  96 
of  uterus,  207 
Endosalpinx,  255 

Endothelioma  differentiated  from  carci- 
noma of  uterus,  411 
of  uterus,  411 
End-to-end  approximation  of  broad  Uga- 

ments,  634 
Enteric  fever,  a  cause  of  atrophic  metritis, 

252 
Enterocele  vaginalis,  anterior,  623 

posterior,  623 
Enteroptosis  as  compMcation  to  descent 

of  uterus,  646 
Enucleation  of  myoma  of  uterus,  375 
Epididymis,  492 
Episiotomy,  529 
Epispadias,  507 

Epithelium,  pavement-cell,  410 
Epoophoron,  development  of,  492 
Ergot,  373 

Erosion  of  cervix  uteri,  220,  556 
folhcular,  556 
granular,  556 
papillary,  220,  556 
simple,  220 
Erysipelas   mahgnum   internum   of  Vir- 

chow,  269,  273 
Erysipelatous  vulvovaginitis,  187 
erythematous,  187 
gangrenous,  187 
treatment  of,  188 
vesicular,  187 
Eversion  of  anus  in  digital  examination, 

59 
•    of  cervix  uteri,  223 
Examination  of  anus,  77 
proctoscope  in,  77 
sigmoidoscope  in,  77 
by  auscultation,  66 
conjoined,  59 


Examination,    conjoined,   anaesthesia  in, 
64 
rectal,  62 
rectovaginal,  64 
roots  of  sciatic  nerve  in,  65 
traction  as  aid  to,  64 
vaginal,  59 
with  sound,  65 
digital,  57 

conduct  of,  59 

distension  of  bladder  during,  58 
eversion  of  anus  in,  59 
left-hand  method  in,  57 
exploratory  incision  in,  89 
by  inspection,  56 
instrumental,  68 

diagnostic  curettage  in,  77 
exploratory  needle  and  aspirator  in, 

77 
left  lateroprone  position  in,  70 
probe  in,  75 
sound  in,  75 
speculum  in,  68 
Sims',  68 

self-retaining,  68 
mensuration  in,  67 
by  palpation,  66 
by  percussion,  66 
physical,  55 
table  in,  55 
of  young  girls,  56 
of  rectum,  77 

proctoscope  in,  77 
sigmoidoscope  in,  77    - 
of  urinary  organs,  77 

catheterization  in,  80 
cystoscopy  in,  80 
cylindrical,  80 
dorsal  position  in,  81 
electrical,  83 

knee-breast  position  in,  83 
value  of,  86 
inspection  in,  79 
palpation  in,  79 
percussion  in,  79 
Rontgen  skiagram  in,  79  _ 
ureteral  catheterization  in,  value 
of,  86 
exploration  in,  80 
urethroscopy  in,  80 
urinalysis  in,  78 
Excoriation  of  cervix  uteri,  556 
Excretory  organs,  embryology  of,  486 
ExfoUative  cystitis,  337,  345 

endometritis,  231,  232 
Extra-uterine  pregnancy,  469.    See  Tubal 

pregnancy. 
Exudative  cystitis,  336 
peritonitis,  274 


F 


Facies  ovariana,  443 

uterina,  443 
Fallopian  tubes,  absence  of,  496 


INDEX 


ll'.i 


Fallopian  tubes,  accessory,  49G 
iiilenoma  of,  464 
atlenoinyonia  of,  464 
carcinoma  of,  464 
clinical  significance  of,  496 
conservative  oi)eration  on,  322 
cysts  of,  464 

exces-sivc  convolution  of,  496 
increased  length  of,  496 
interstitial  portion  of,  ampulla,  256 
fimbriated  extremity,  256 
isthmus,  256 
malformation  of,  496 
myoma  of,  464 

rudimentary'  development  of,  496 
sarcoma  of,  465 

senile  changes  in,  at  menopause,  30 
supernumerary,  496 
tumors  of,  464 
Fecal   accumulation,  differentiated  from 
ovarian  cj'sts,  448 
from  salpingitis,  266 
fistula  after  abdominal  operations,  163 
from  abdominal  drainage,  143 
Fibroids,  recurring,  423 
Fibroma  of  ovary,  427 

of  round  ligament,  465 
Fibromyoma  of  vagina,  357 
treatment  of,  357 
of  vnilva,  355 

treatment  of,  355 
Filaria  sanguinis  hominis  in  hsematoma 

of  vulva,  350 
Fissure  cystitis,  337 
Fistula,  anovaginal,  605 
genital,  572 

priority  iii  operation  for,  572 
varieties  of,  573 
rectovaginal,  604 
causes  of,  604 
diagnosis  of,  604 
operation  for,  605 
prognosis  of,  604 
ureteral,  to  external  surface,  in  abdom- 
inal section,  295 
uretero-uterine,  405 
ureterovaginal,  405,  597 
acquired,  597 
causes  of,  598 
congenital,  597 
diagnosis  of,  598 
traumatic,  result  of  trachelorrhaphy, 

600 
treatment  of,  598 

Dudley  clamp  operation  in,  598 
urethrovaginal,  597 
vesico-uterine,  597 
diagnosis  of,  597 
treatment  of,  597 
vesicovaginal,  573 
cause  of  cystitis,  574 

of  sterility,  756 
course  of,  574 
diagnosis  of,  574 

differential,    from    ureterovaginal 
fistula,  574 


Fistula,  vesicovaginal,  etiology  of,  573 
prognosis  of,  575 
symptoms  of,  574 
treatment  of,  projjhylactic,  575 
surgical,  576 

atypical  operations,  589 
Kelly's  operation,  596 
kolpokleisis,  590 
loss  of  entire  vesicovaginal  sep- 
tum, 589 
operation  for  closing,  581 
after-treatment  of,  587 
appHcation    of    sutures    in, 

586 
choice  of  speculum,  582 
denudation  in,  584 
direction  of  line  of    union 

in,  583 
method  of  operation,  582 
preparatory   treatment    of, 
582 
preparatory,  576 
cystitis  in,  577 

direction  and  manner  of  clo- 
sure, 577 
phosphatic  deposits  in,  576 
stone  in  bladder  in,  577 
Flushing  of  peritoneal  cavit}-,  144 
Foetus,  calcareous  degeneration  of,  482 
encapsulated,  482 
mummification  of,  482 
Follicular  erosion,  221 
ovarian  cysts,  429 
vulvitis,  194 

treatment  of,  195 
Forceps,  vuLseUa,  101 
Foreign-body  cystitis,  337 
Fowler's  position  in  abdominal  drainage, 

152 
Furunculosis,  189,  196 
treatment  of,  196 


G 


G.vertxer's  ducts,  332,  356,  436,  492 

Garrulity  of  \ailva,  528 

Gauze  sponges,  sterihzation  of,  40 

sterilization  of,  40 
Generative  organs,  embryology  of,  490 
Genital  fistula,  572 

priority  in  operation  for,  572 
varieties  of,  573 
ridge,  development  of,  486,  491,  493 
Gestation,    normal,    differentiated    from 
ovarian  cysts,  449 
in    one    horn    of    bifurcated    uterus, 
differentiated  from  ovarian  cysts,  450 
GilUam  t^-pe  of  operation,  672 
Glands  of  Bartholin,  192 
Glandular  endometritis,  hyperplastic,  229 
hj'pertrophic,  228 
interstitial  and,  229 
enlargement  of  cervix  uteri,  220 
cvstic,  221 
pohTJoid,  220 


774 


INDEX 


Glandular  vulvitis,  192 
diagnosis  of,  194 
treatment  of,  194 
Glycerin  emollient,  42 
Goitre  of  puberty^  27 
Gonococcus,  33 

a  cause  of  cystitis,  334 

of  ovaritis,  277 
of  Neisser,  184 

in  metritis,  211 
in  Skene's  glands,  327 
Gonorrhoea  complement-fixation  test,  184 

recurrent,  327 
Gonorrhoeal  cystitis,  339 
papilloma  of  vulva,  352 

treatment  of,  353 
salpingitis,  283 
vulvovaginitis,  183 
diagnosis  of,  184 
prognosis  of,  184 
treatment  of,  186 
Gout  a  cause  of  chronic  metritis,  248 
Graafian  follicles,  25,  170,  429 

absent  or  rudimentary,  495 
Granulation  of  cervix  uteri,  556 

coxcomb,  556 
Gynandry,  510 

a  cause  of  sterility,  753 
Gynatresia,  congenital,  513 
diagnosis  of,  514 
pathological  results  of,  513 
prognosis  of,  517 
symptoms  of,  513 
treatment  of,  517 


H 


HEMATOCELE,     pelvic,     resulting     from 

tubal  pregnancy,  476 
Hsematocolpos,  502,  519 

operations  for,  519 
Hsematoma,  pudendal,  521 
of  vulva,  350 

treatment  of,  350 
Hsematometra,  515,  519 

abdominal  hysterectomy  Jor,  518 
artificial  vagina  for,  518 
differentiated  from  ovarian  cysts,  452 
operations  for,  517 
ovaries,  removal  of,  for,  518 
Hsematosalpinx,  260 

HiEmostasis,  intraperitoneal,  during  oper- 
ation, 127 
Hemorrhage  in  carcinoma  of  uterus,  405 
differentiated   from   tubal   pregnancy, 

480  _ 
in  major  operations,  155 
diagnosis  of,  155 
treatment  of,  155 
in  myoma  of  uterus,  364,  373 
technique   in,   in   treatment   of   pelvic 

inflammations,  293 
in  trachelorrhaphy,  564 
uterine,  736 

causes  of,  displacements,  737 


Hemorrhage,  uterine,  causes  of,  foreign 
bodies,  738 
inflammations,  736 
extra-uterine,  737 
uterine,  736 
systemic  disorders,  738 
tumors,  737 
uterine  moles,  738 
cystic,  738 
fleshy,  738 
hydatiform,  739 
visceral  diseases,  738 
diagnosis  of,  740 
during  maturity,  741 

menopause,  741 
etiology  of,  736 
of  girls,  740 
tampons  in,  95 
treatment  of,  741 

Boldt's  remedy  in,  741 
local,  742 
surgical,  742 

hypodermoclysis  in,  742 
direct  transfusion  in,  742 
systemic,  741 
from  vagina,  tampon  in,  95 
Hermaphrodism,  510 

treatment  of,  512 
Hernia  from  abdominal  drainage,  143 
of  bladder,  632 
omental,    differentiated   from   myoma 

of  round  ligament,  465 
of  ovary,  728 
diagnosis  of,  728 
differentiated  from  myoma  of  round 

ligament,  465 
treatment  of,  728 
of  uterus,  728 
diagnosis  of,  728 
treatment  of,  728 
Herniation  of  ovary,  495 
Herpes  of  vulvae,  198 
Hummelfarb's     treatment     for     inconti- 
nence of  urine,  759 
Hydatid  cysts  differentiated  from  ovarian 
cysts,  454 
of  Morgagni,  436 

differentiated  from  ovarian  cysts,  452 
Hydramnios,  differentiated  from  ovarian 

cysts,  449 
Hydrastin,  373' 
Hydrocele,  ovarian,  260 

differentiated  from  ovarian  cysts,  452 
of  round  ligament,  465 
Hydrometra,  232 

differentiated  from  ovarian  cysts,  452 
Hydronephrosis  differentiated  from  ovar- 
ian cysts,  456 
Hydrosalpinx,  260 

aspiration  of,  through  vagina,  317 
technique  of,  317 
Hymen,    imperforate    or    cribriform,     a 
cause  of  sterihty,  753 
malformations  of,  503 
Hypergesthesia  of  vulva,  204 
treatment  of,  205 


INDEX 


Hyperplasia,  areolar,  2r)0 
Hyperi)lastie  glandular  ciidoinetritis,  229 
llypertropliic  glaiulular  cndoiiietritis,  228 
"metritis,  249 

noii-piierperal,  249 
puerperal,  249 
Hypertri)i)hy  of  cervix,  555 

dilTerentiated     from     carcinoma     of 
uterus,  409 
of  clitoris,  50S 
of  nx'mplue,  oOS 
of  ovaries,  congenital,  495 
of  prejjuce,  50S 
Hypodermoclysis  in  treatment  of  uterine 

hemorrhage,  373,  742 
Hypospadias,  507 

Hvsterectomy,   abdominal,   for   ha^mato- 
metra,  518 
indications  for,  286 

in  treatment  of  carcinoma  of  uterus, 
413 
ignihysterectomj-,  417 
paravaginal,  413 
radical  abdominal,  415 
descent  of  uterus,  G2S 
inversion  of  uterus,  723 
pelvic  inflammations,  283 
technique  in,  295 
vaginal,  299 

in  treatment  of  mj'oma  of  uterus,  375 
wounding  of  ureter  in,  602 
without  removal  of  appendages,  286 
Hysterical  vomiting,  159 

treatment  of,  160 
Hysteromyomectomy,  complete  abdomi- 
nal, for  myoma  of  uterus,  386 
supravaginal,  for  myoma  of  uterus,  384 
Hystero-oophor-salpingectomy    in    treat- 
ment of  pelvic  inflammations,  284 
Hysterorrhaph}',  abdominal,  678 
for  descent  of  uterus,  646 
technique  of,  680 
vaginal,  682 


Ichthyosis  of  uterus,  difTerentiated'from 

carcinoma,  410 
Ignihvsterectomj'  in  carcinoma  of  uterus, 
417 
historj'  and  rationale  of,  418 
Incision  of  uterus,  116 

Dudley's  method,  118 
Shroeder's  method,  118 
Incontinence  of  urine,  758 
active,  758 
passive,  758 
treatment  of,  759 

by  advancing  of  urethra,  759 
Hummelfarb's  method,  759 
Pawlik's  method,  759 
by  Dudlej-'s  operation,  763 
by  injection  of  paraffin,  759 
by  massage  and  electricity,  759 
by  torsion  of  urethra,  759 


Infantile  uterus,  497 

vulva,  507 
Infection,  32 

bj-  continuity  of  mucosa,  171 
definiti(Mi  of,  169 
forms  of,  32 

bacillus  coli  communis,  34 

tuberculosis,  34 
bacterial,     distinguished     from     one 

another,  263 
gonococcus,  33 
staphylococcus  pyogenes  albus,  33 

aureus,  33 
streptococcus  pyogenes,  33 
by  lymphatics  and  bloodvessels,  172 
in  salpingitis,   incoming  and  outgoing 
routes  of,  25f) 
Inflammations,  169 
acute  i)elvic,  262 
adnexal,  261 

differentiation  of,  264 
bacterial   vulvovaginal,    special   forms 

of,  183 
classification  of,  173 
acute,  174 
chronic,  174 
course  of,  171 
definition  of,  169 
diagnosis  of,  176 
etiology  of,  170 

exciting  causes,  171 
favoring  conditions,  170 
general,  170 
local,  170 
pathology  of,  171 
pelvic,  treatment  of,  280 
non-surgical,  280 
.    surgical,  283 

by  abdominal  section,  287 
by  vaginal  section,  296 
prognosis  of,  176 
significance  of,  274 
treatment  of,  176 
of  urethral  crj-pts,  192 
of  uterine  appendages,  261 
uterine,  a  cause  of  hemorrhage,  736 

a  cause  of  profuse  leucorrhoea,  736 
of  uterus.    See  Metritis, 
vulvovaginal,  bacterial,  183 
of  glands,  192 
Inguinal  glands,  enlarged,  differentiated 

from  niA'oma  of  round  ligament,  465 
Instrumental  examination,  68 
diagnostic  curettage  in,  77 
exploratory  needle  and  aspirator  in, 

77 
left  lateroprone  position  in,  70 
probe  in,  75 
sound  in,  75 
speculums  in,  68 
Intermenstrual  pain,  periodic,  748 
Interstitial  cystitis,  335 
endometritis,  229 
metritis,  250 
pregnane}',  471 
sarcoma  of  uterus,  423 


776 


INDEX 


Intestinal  opening  in  abdominal  section, 

293 
Intra-abdominal     shortening     of     round 
ligament    in    retroflexion    and    retro- 
version of  uterus,  672 
Intraligamentous  cyst  of  ovary,  462 

myoma  of  uterus,  382 
Intramural  myoma  of  uterus,  361 
Intraperitoneal  hsemostasis  during  opera- 
tion, 127 
Intrauterine  treatment,  selection  of  cases 

for,  97 
Inversion  of  uterus,  711 
anatomy  of,  714 
chronic,  717 
diagnosis  of,  715 
etiology  of,  711 
mechanism  of,  714 
pathology  of,  714 
prognosis  of,  717 
symptoms  of,  715 
treatment  of,  acute,  717 
chronic,  718 

by  colpeurynter,  721 

by  elastic  pressure,  721 

by  hysterectomy,  723 

by  incision,  723 

manual,  Emmet's  method,  720 

Tate's  method,  721 
methods  of,  718 
obstacles  to,  718 
preparatory,  720 
by  water-bag,  721 
Iodine  as  an  antiseptic  agent,  36 
lodization  by  Claudius'  solution,  40 
Iron,  373 
Isthmic  pregnancy,  473 


Kelly's  cystoscope,  80 

Kidney,    displaced,    differentiated    from 

salpingitis,  266 
floating,  differentiated  from  myoma  of 

uterus,  370 
permanent,  development  of,  487 
Knot,  Staffordshire,  108 
Kobelt's  tubes,  436  _ 

Kolpokleisis  for  vesicovaginal  fistula,  590 
Kraurosis  of  vulva,  198 

a  cause  of  sterility,  755 

diagnosis  of,  199 

pathology  of,  198 

symptoms  of,  199 

treatment  of,  199 

Longyear's  operation,  199 


Laceration  of  cervix  uteri,  anterior,  547 
carcinoma  from,  555 
causes  of,  546 

cicatricial    narrowing    of    uterine 
canal  in,  556 


Laceration   of    cervix    uteri,   cicatricial 
narrowing    of  uterine  canal  in 
reflex  irritation  from,  556 
diagnosis  of,  556 
differential,  558 

from  carcinoma,  411 
from  congenital  eversion,  558 
from  endocervicitis,  558 
directions  and  extent  of,  547 
false  cervix  in,  548,  552 

apparent     hypertrophy     and 

elongation  in,  553 
cystic    degeneration    in,    552, 

556 
descent  and  vaginal  reduph- 

cation  in,  549 
subinvolution  in,  549 
lateral,  548 

pathological  anatomy  of,  546 
posterior,  547 
prophylaxis  of,  559 
puerperal,  546 
results  of,  546 
symptoms  of,  555 
treatment  of,  559 

atypical  lacerations,  566 
resection  of  cervix,  566 
trachelorrhaphy  in,  559 
after  treatment  of,  571 
approximation  in,  563 
denudation  in,  563 
disinfection  in,  562 
hemorrhage  in,  564 
immediate  operation,  559 
preparatory  treatment  of,  560 
removal  of  cicatricial  plug  in, 

563 
results  in,  571 
secondary  operation,  560 
sutures  in,  564 
of  perineum,  cystocele  in,  526 
pathological  results  of,  522 
prophylaxis  in,  528 
puerperal,  521 

complete,  522,  523 
incomplete,  522 
rectocele  in,  526 
Lateral  location  of  uterus,  616 
diagnosis  of,  616 
symptoms  of,  616 
treatment  of,  616 
Leiomyoma,  358 
Leucoplakia  cystitis,  337 
Leucorrhoea,  179,  233 

in  chronic  endocervicitis,  221 
Linen,  sterilization  of,  40 
Lipoma  of  broad  ligament,  465 
of  vulva,  355 

treatment  of,  355 
Liquor   cresolis   comp.   as    an    antiseptic 

agent,  36 
Lithopsedion,  482 

Lithotomy  in  treatment  of  cystitis,  347 
Lithotrity  in  treatment  of  cystitis,  347 
Lubricant  of  vaseline  or  oil,  42 
Lupus,  189,  351. 


INDEX 


Lupus  of  vulva,  356 
Lymphatics,  inlVction  by,  172 
Lysol  as  an  antiseptic  agent,  36 


M 


Major  operations,  121 

abdominal  section,  121 

actual  cautery  in,  127 
adhesion  in,  125 
dressings  and  bandages  in,  138 
dusting  powders  in,  138 
incision  in,  123 
exploratory,  123 
median,    through   linea   alba, 
123 
intraperitoneal  haemostasis,  127  I 
ligatures  in,  127  I 

pressure  forceps  in,  127 
sponges  in,  132 

how  to  avoid  leaving  in  abdo- 
men. 133 
treatment  for,  preparatory,  123 
Trendelenburg  position  in,  121 

substitute  for,  123 
wound,  closm-e  of,  127 

buried  sutures  in,  129 
mattress  sutures  in,  130 
Michelle  clips  in,  130 
after-treatment  of,  152 
complicated  cases,  155 
fecal  fistula  in,  163 
hemoiThage  in,  155 
diagnosis  of,  155 
hjpodermoclysis  after,   156 
treatment  of,  155 
hysterical  vomiting,  159 

treatment  of,  160 
obstruction  of  bowels,  161 
causes  of,  160 
diagnosis  of,  161 
prognosis  of,  161 
treatment  of,  161 
removal  of  sutures  in,  162 
salt      water     infusion,      drop 

method  of,  157 
sepsis  in,  157 
general,  158 
locaUzed.  158 
stitch  abscess,  158 
treatment  of,  158 
shock  in,  155 
sinuses  in,  162 

prevention  of,  162 
stomach  dilatation  in,  acute, 

160 
urinary  fistula  in,  163 
ventral  hernia  in,  163 
simple  cases,  152 
bladder  in,  154 
bowels  in,  153 
care  of  cicatrix,  154 
food  in,  154 
getting  up  in,  154 
hot-water  bags  in,  153 


Major     operations,    after-treatment     of 
simple  cases,  pain  in,  154 
position,  152 
rest  in,  152 

for  stomach,  153 
thirst  in,  153 
drainage  in,  142 

comparison  of  results  of,  142 
evil  results  of,  143 
fecal  fistula,  143 
hernia,  143 

obstruction  of  bowel,  143 
vesical  complications,  143 
forms  of,  146 
abdominal,  149 
capillary,  146 
tubular,  146 
vaginal,  150 
gauze  packing  in,  use  of,  147 
in  infectious  cases,  142 
in  non-infectious  cases,  142 
peritoneal,    contraindications    for, 
145 
indications  for,  146 
preventing  infection  of,  143 
flushing  peritoneal  cavity  in,  144 
sacral  resection,  141 
vaginal  section,  140 
MaKormations,  349 
of  anus,  503 
of  clitoris,  508 
congenital,  494 
of  Fallopian  tubes,  496 
of  hymen,  503 
of  nymphae,  508 
of  ovaries,  494 
of  prepuce,  508 
of  uterus,  496 
of  vagina,  501 
■    of  vulva,  503 
Mal-locations  of  uterus,  615 
Malpositions  of  uterus,  648 
Mammae,    senile    changes    in,    at    meno- 
pause, 30 
Maturity,  29 
Menopause,  29 
basis  of,  30 
anatomical,  30 
physiological,  30 
phenomenon  of,  30 

senile  change  in  Fallopian  tubes  at,  30 
in  mammae  at,  30 
in  ovarj'  at,  30 
in  uterus  at,  30 
in  vagina  at,  30 
in  vulva  at,  30 
sjTnptoms  of,  30 
abnormal,  31 
normal,  30 
Menorrhagia.     See  Uterine  hemorrhage. 
Menstrual  fluid,  retained,  513 
Menstruation,  23 
age  of  first,  24 
anatomy  of,  24 
disorders  of,  729 
duration  of,  24 


778 


INDEX 


Menstruation,  frequency  of,  24 
phenomena  of,  23 
general,  23 
local,  23 
precocious,  24 
premature,  729 
causes  of,  730 
treatment  of,  730 
protracted,  24,  730 
quantity  of  discharge  in,  24 
scanty,  24,  735 
Mercuric    bichloride,    alcoholic    solution 
of,  45 
chloride  as  an  antiseptic  agent,  36 
Mesonephros,  development  of,  487 
Metanephros,  development  of,  487 
Metritis,  207 
acute,  211 

bacillus  coh  communis  in,  212 
diphtherise  in,  212 
tuberculosis  in,  212 
diagnosis  of,  214 
etiology  of,  211 

exciting  causes,  211 
predisposing  causes,  211 
gonococcus  of  Neisser  in,  211 
pathology  of,  212 
prognosis  of,  214 
sharp  curette,  use  of,  in,  217 
staphylococcus  in,  212 
streptococcus  in,  212 
symptomatology  of,  213 
symptoms  of,  213 
treatment  of,  214 
general,  215 
prophylactic,  215 
surgical,  215 
atrophic,  251 

non-puerperal,  252 
puerperal,  251 
a  cause  of  amenorrhcea,  731 
chronic,  248 

arteriosclerosis  and,  253 
diagnosis  of,  253 
differential,  253 

from  carcinoma  of  uterus,  410 
dysmenorrhoea  and,  745 
etiology  of,  248 

exciting  causes,  249 
predisposing  causes,  248 
modes  of  infection  in,  248 
pathology  of,  249 
physical  signs  of,  253 
symptoms  of,  253 
treatment  of,  254 
cirrhotic,  pathology  of,  250 
classification  of,  210 
diagnosis  of,  from  myoma  of  uterus,  368 
differentiated  from  ovarian  cysts,  451 
general  considerations  of,  207 
hyperplastic,  areolar,  250 
hypertrophic,  non-puerperal,  249 
pathology  of,  249 
puerperal,  249 
interstitial,  pathology  of,  250 
MetroiThagia-     See  Uterine  hemorrhage. 


Microcystic  degeneration  of  ovary,  279 
Micro-organisms,   cause  of  septic  infec- 
tion, 32 
Minor  operations,  99 
apphances  for,  100 
curettage  of  uterus,  118 

technique  of,  120 
denudation,  106 
dilatation  of  uterus,  109 

diverging  instruments  in,  114 

extent  of,  115 

forcible,  dangers  of,  116 

technique  of,  116 
graduated  bougies  in,  114 
tents  in,  109 

with  intra-uterine  medication, 
111 
during  pregnancy,  100 
incision  of  uterus,  116 

Dudley's  ihethod,  118 
Shroeder's  method,  118 
instruments  in,  100 
forceps,  101 
needles,  103 
scissors,  103 
speculums,  101 
sponge  holders,  103 
uterine  tenaculum,  103 
ligatures  for,  107 
multiple,  100 

needle  forceps  in,  how  to  handle,  106 
plastic,  105 

Staffordshire  knot  in,  108 
sutures  in,  106 

removal  of,  109 
tables  for,  100 
technique  of,  105 
time  to  operate  in,  99 
treatment  of  preparatory,  99 
union  bv  first  intention  in,  105 
Mittelschmerz,  748,  749 
Moles,  uterine,   a  cause  of  hemorrhage, 

738 
Monocyst,  429 

Morcellation  of  myoma  of  uterus,  375 
Mucous  polypi  of  urethra,  467 

of  uterus,  229 
Multilocular  ovarian  cysts,  429 
Mueller's  ducts,  356,  501 
Mycotic  vulvovaginitis,  189 
clinical  history  of,  189 
diagnosis  of,  190 
etiology  of,  189 
prognosis  of,  190 
symptoms  of,  189 
treatment  of,  190 
Myofibroma,  358 
Myoma  of  broad  hgament,  465 

differentiated  from  cyst  of  round  liga- 
ment, 465 
of  Fallopian  tubes,  464 
of  ovary,  427 
of  round  ligament,  465 
subserous    differentiated    from    pelvic 

celluhtis,  273 
of  uterus,  358 


IXDEX 


r9 


Mj'oma  of  uterus,   classification   of,   \)y 
location,  301 
cervical,  364 
intramural,  361 
submucous,  362 
pedunculated,  362 
primaril}',  362 
secondarily,  362 
subperitoneal,  363 
intraligamentous,  363 
subserous,  363 
diagnosis  of,  366 

conjoined  examination  in,  366 
exploration  by  sound,  367 
intra-uterine,  367 
differential,  367 

from  carcinoma,  368 
complicating  pregnancy,  368 
from    displacements   of   uterus, 

369 
from  floating  kidney,  370 
from  incomplete  abortion,  369 
from    intra-uterine    pregnancy, 

367 
from  metritis,  368 
from  ovarian  c-\'sts,  450 
from  ovar}',  369 
from  pelvic  cysts,  370 

inflammatory  infiltrations,  369 
from  sactosalpinx,  370 
from  sarcoma,  368 
from  tubal  pregnane}^,  368 
inspection  and  palpitation  in,  366 
a--ray  in,  367,  368,  370 
Dudlej-'s  incision  in,  377 
etiolog}^  of,  358 
intraligamentous,  382 
natural  cure  of,  371 
pathology-  of,  358 
prognosis  of,  371 

after-operation  for,  401 
non-operative,  371 
operative,  371 
sarcomatous  degeneration  of,  424 
secondary  changes  of,  359 
calcification,  359 
fatty  degeneration,  359 
gangrene,  359 
malignant  changes,  360 
mucoid  degeneration,  359 
septic  infection,  359 
symptoms  of,  364 
hemorrhage,  364 
intermenstrual  uterine  discharge, 

366 
pain  and  discomfort,  365 
pressure,  372 
treatment  of,  372 

abdominal  myomectomy  in,  378 

drainage  in,  380 
electrolysis  in,  372 
hysteromyomectomy,    complete 
abdominal,  386 
technique  of,  386 
supravaginal  in.  384 
technique  of,  384 


Myoma  of   uterus,    treatment   of,    non- 
surgical, 372 
manipulation,  372 
surgical,  374 

palliative  ()]K;rations,  375 
radical    abdominal    operations, 
378 
vaginal  operations,  375 
torsion  in,  375 

vaginal  enucleation  and  morcella- 
tion  in,  375 
hystei'ectomy  in,  375 
x-ray  in,  372 
Myomata,  intramural,  375 
Myomectomv,    abdominal,    drainage    in, 
380 
in  treatment  of  myoma  of  uterus,  378 
during  pregnancy,  401 
Myosalpinx,  255 


N 


Neisser,  gonococcus  of,  33,  184 

Nephrectomy,  295 

Nephritis,  348,  405 

Nerve  counterfeits  of  pelvic  disease,  51 

exhaustion,  51 

strain,  51 
Neuroma  of  \iilva,  356 
Non-puerperal  traumatisms,  521 
Novocaine,  344 
Nj-mphae,  h\T3ertroph3'  of,  508 

malformations  of,  508 


Oophorectomy   in   treatment    of   pelvic 

inflammations,  283 
Oophor-salpingectomy    in    treatment    of 

pehac  inflammations,  284 
Operations,  aseptic,  preparation  for,  43, 
46 
major,  121 

abdominal  section,  121 
actual  cautery  in,  127 
adhesion  in,  125 
antipjTine  in,  127 
closure  of  wound,  127 

buried  sutures  in,  129 
mattress  sutures  in,  130 
Michelle  cUps  in,  130 
dressings  and  bandages  in,  138 
dusting  powders  in,  138 
incision  in,  123 
exploratory,  123 
median,    through   hnea   alba, 
123 
intraperitoneal  hsemostasis,  127 
ligatures  in,  127 
operating  tables  in,  121 
pressure  forceps  in,  127 
sponge  pressure  in,  127 
sponges  in,  132 
treatment  for,  preparatory,  123 


780 


INDEX 


Operations,    major,    abdominal    section, 
Trendelenburg     position 
in,  121 
substitute  for,  123 
after-treatment  of,  152 
complicated  cases,  155 
fecal  fistula  in,  163 
hemorrhage  in,  155 
diagnosis  of,  155 
hypodermoclysis  after,  156 
treatment  of,  155 
hysterical  vomiting,  159 

treatment  of,  160 
obstruction  of  bowels,  161 
causes  of,  160 
diagnosis  of,  161 
prognosis  of,  161 
treatment  of,  161 
removal  of  sutures,  162 
salt     water     infusion,     drop 

method  of,  157 
sepsis  in,  157 
general,  158 
localized,  158 
stitch  abscess,  158 
treatment  of,  158 
shock  in,  155 
sinuses  in,  162 

prevention  of,  162 
stitch  abscess  in,  158 
stomach  dilatation  in,  acute, 

160 
urinary  fistula  in,  163 
ventral  hernia  in,  163 
simple  cases,  152 

care  of  bladder  in,  154 
of  bowels  in,  153 
of  cicatrix  in,  154 
food  in,  154 
getting  up  in,  154 
hot-water  bags  in,  153 
pain  in,  154 
position,  152 
rest  in,  152 

for  stomach,  153 
thirst  in,  153 
drainage  in,  142 

comparison  of  results  of,  142 
evil  results  of,  143 
fecal  fistula,  143 
hernia,  143 

obstruction  of  bowel,  143 
vesical  complications,  143 
forms  of,  146 
abdominal,  149 
capillary,  146 
tubular,  146 
vaginal,  150 
gauze  packing  in,  use  of,  147 
in  infectious  cases,  142 
in  non-infectious  cases,  142 
peritoneal,    contraindications    for, 
145 
indications  for,  146 
to  prevent  infection,  143 
flushing  peritoneal  cavity  in,  144 


Operations,  major,  sacral  resection,  141 
vaginal  section,  140 
minor,  99 

appliances  for,  100 
curettage  of  uterus,  118 

technique  of,  120 
denudation,  106 
dilatation  of  uterus,  109 

diverging  instruments  in,  114 

extent  of,  115 

forcible,  dangers  of,  116 

technique  of,  116 
graduated  bougies  in,  114 
tents  in,  109 

with  intra-uterine  medication, 
111 
during  pregnancy,  100 
incision  of  uterus,  116 

Dudley's  method,  118 
Shroeder's  method,  118 
instruments  for,  101 
forceps,  101 
needles,  103 
scissors,  103 
speculums,  101 
sponge  holders,  103 
uterine  tenaculum,  103 
ligatures  in,  107 
multiple,  100 

needle  forceps  in,  how  to  handle,  106 
plastic,  105 

Staffordshire  knot,  108 
sutures  in,  106 

removal  of,  109 
tables  for,  100 
technique  of,  105 
time  to  operate  in,  99 
treatment  of,  preparatory,  99 
union  by  first  intention,  105 
Orthoform  for  vulvovaginitis,  182 
Os  uteri,  pinhole,  225 
Ova,  429 
Ovarian  cysts,  429 

corpus  luteum,  431 
cyst-adenomata,  431 
papillary,  432 
simple,  431 
dermoid,  434 
complicated,  436 
simple,  435 
diagnosis  of,  444 
adhesions,  445 
clinical  history  in,  444 
conjoined  examination  in,  445 
differential,  447 
from  ascites,  454 
from  dilated  stomach,  448 
from  distended  bladder,  448 
from  fat  in  abdominal  wall,  448 
from  fecal  accum.ulations,  448 
from  gestation  in  one  born  of 

bifurcated  uterus,  450 
from  haematometra,  452 
from  hydatid  cysts,  454 

of  Morgagni,  452 
from  hydramnios,  449 


INDEX 


781 


Ovarian  cysts,  diagnosis  of,  differential, 
from  hj'dromctra,  452 
from  liydronopliro.sis,  451) 
from  metritis,  4")! 
from  normal  gestation,  449 
from  ovarian  hydrocele,  452 
from  i)hantom  tumor,  448 
from  physometra,  452 
from  i)yometra,  452 
from  renal  tumors,  455 
from  tubal  pregnancy,  450 
from  tympanites,  448  • 
from  uterine  carcinoma,  451 
myoma,  450 
sarcoma,  451 
inspection  in,  444 
malignancy,  446 
measurements  in,  445 
palpitation  in,  444 
percussion  in,  444 
exploratory  incision  in,  456 
follicular,  429,  430 
multilocular,  429,  431 
pathology  of,  429 
prognosis  of,  456 
proliferating.  431 
removal  of,  457 

abdominal  incision  in,  457 
accidents  in,  461 
after-treatment  in,  461 
closure  of  wound  in,  461 
comphcations  in,  461 

extrusion  of  the  bowel,  461 
foreign  bodies  left  in  abdomen, 

462 
injuries  to  intestines,  ureter,  and 

bladder,  462 
intestinal  obstruction,  462 
ruptiu-e  of  cyst  wall,  462 
stripping  of  parietal  peritoneum 
from  abdominal  wall,  462 
delivery  of  cyst  in,  457 
adhesions  in,  461 
secondary'  cysts  in,  461 
semisolid  contents  in,  461 
drainage  in,  461 
emptying  of  cyst  in,  457 
ligature  of  pedicle  in,  461 
preparatory'  treatment  in,  457 
secondary  changes  in,  439 
fluid  contents,  439 
infection,  440 
adhesions,  440 
diagnosis  of,  445 
suppuration,  440 
rupture  of,  441 
causes  of,  441 
diagnosis  of,  445 
results  of,  442 
twisting  of  pedicle,  441 
diagnosis  of,  445 
torsion,  acute,  441 
chronic,  441 
symptoms  of,  442 

facies  ovariana,  443 
unilocular,  429 


Ovarian  extracts,  285 
hydrocele,  260 

dilTcrciitiated  from  ovarian  cysts,  452 
neuralgia,  dilTerentiated  from  ovaritis, 

279 
pregnancy,  469 

tumors  differentiated  from  tubal  preg- 
nancy, 480 
Ovaries,  absence  of,  494 
accessory,  494 
benign  papilloma  of,  427 
carcinoma  of,  427 
conservative  operation  on,  324 
contraction  of,  748 
cortex  of,  429 

cyst  of,  intrahgamcntous,  462 
desiccated,  285 
differentiated  from  myoma  of  uterus, 

369 
displacement  of,  congenital,  495 
fibroma  of,  427 
hernia  of,  728 

diagnosis  of,  728 

treatment  of,  728 
herniation  of,  495 
hjTDertrophy  of,  congenital,  495 
malformation  of,  494 

clinical  significance  of,  495 

diagnosis  of,  496 
medullary  portion  of,  429 
microcj'stic  degeneration  of,  279 
myoma  of,  427 

removal  of,  for  hsematometra,  518 
resection  of,  324 

operation  of,  325 
rudimentary,  495 
sarcoma  of,  427 
sclerosis  of,  748 

senile  changes  in,  at  menopause,  30 
supernumerarj^  494 
teratomata  of,  436 
tumors  of,  solid,  427 
diagnosis  of,  427 
treatment  of,  428 
vascular  portion  of,  429 
Ovariotomy,  457 

abdominal  incision  in,  457 
accidents  in,  461 
after-treatment  in,  461 
closure  of  wound  in,  461 
complications  in,  461 

extrusion  of  the  bowel,  461 

foreign  bodies  left  in  abdomen,  462 

injuries    to    intestines,    ureter,    and 
bladder,  462 

intestinal  obstruction,  462 

rupture  of  cyst  wall,  462 

stripping  of  parietal  peritoneum  from 
abdominal  wall,  462 
delivery  of  C3'st  in,  457 
adhesions  in,  461 
secondary  cysts  in,  461 
semisoUd  contents  in,  461 
drainage  in,  461 
dirring  pregnancy,  463 
emptying  of  cyst  in,  457 


782 


INDEX 


Ovariotomy,  ligature  of  pedicle  in,  461 
preparatory  treatment  for,  457 
vaginal,  463 
Ovaritis,  277 
acute,  278 
chronic,  278 

dysmenorrhoea  and,  745 
diagnosis  of,  278 
differential,  279 

from  appendicitis,  279 
from  ovarian  neuralgia,  279 
from  pelvic  cellulitis,  279 
peritonitis,  279 
etiology  of,  277 

pathology  of,  comparative,  278 
symptoms  of,  278 
treatment  of,  279,  280 
Ovula  Nabothi,  220 
Ovulation,  25 


Pachydermia  of  vulva,  350 
Pachyperitonitis,  276 
Papilloma  of  vulva,  351 
gonorrhoeal,  352 

treatment  of,  353 
non-specific,  352 

treatment  of,  352 
simple,  352 

treatment  of,  352 
syphilitic  flat,  353 
Paracystitis,  335 
Paradidymis,  492 
Parametritis,  268 

pelvic,  268 
Paravaginal  hysterectomy  in  carcinoma 

of  uterus,  413 
Paravaginitis,  188 
Paroophoron,  development  of,  492 
Parovarian  cysts,  429,  436.    See  Ovarian 
cysts, 
broad  ligament,  438 
pathology  of,  436 
Parovarium,  429,  436 
development  of,  492 
Pawlik's   treatment   for   incontinence   of 

urine,  759 
Pedicle,  ligature  of,  in  removal  of  ovarian 

cysts,  461 
Pelvic  celluhtis,  268 
anatomy  of,  268 
diagnosis  of,  270 
differential,  272 

from  appendicitis,  272 
from  hgematocele,  272 
from  ovaritis,  279 
from  peritonitis,  272 
from  psoas  abscess,  273 
from  pyosalpinx,  272 
from  subserous  myoma,  273 
from  tubal  pregnancy,  480 
etiology  of,  268 
pathology  of,  269 
associated,  270 


Pelvic  cellulitis,  prognosis  of,  273 
symptoms  of,  270 
treatment  of,  273,  280 
cysts    differentiated    from    myoma    of 

uterus,  370 
hsematocele  differentiated  from  cellu- 
htis, 272 
inflammation,  acute,  262 
treatment  of,  280 

abscesses  in,  opening  and  draining 

of,  296 
non-surgical,  280 
by  electricity,  282 
general,  280 
by  hot  hip  pack,  282 
by  hot-water  vaginal  douche,  282 
local,  282 
by  massage,  282 
medical,  280 

by  wool  vaginal  tamponade,  282 
surgical,  283 

by  abdominal  section,  287 
advantages  of,  321 
complications  of,  290 
dangers  of,  290 
difficulties  of,  290 
drainage  in,  290 
Dudley's  reefing  operation 

in,_  288 
incision  in,  287 
injury  to  intestine  in,  290 
sponges  in,  use  of,  287 
choice  of  route  in,  321 
by  hysterectomy,  283,  295 
hystero-oophor-salpingectomy, 

284 
oophorectomy  in,  283 
oophor-salpingectomy,  284 
routes  of  operation,  287 
salpingectomy  in,  283 
salpingo-oophorectomy,  284 
by  vaginal  section,  296 
advantages  of,  321 
anterior,  297 
posterior,  296 
parametritis,  268 
peritonitis,  273 
diagnosis  of,  277 
differential,  277 
from  cellulitis,  272 
from  ovaritis,  279 
from  tubal  pregnancy,  480 
etiology  of,  273 
pathology  of,  274 
symptoms  of,  276 
treatment  of,  277,  280 
suppuration,    acute,    vaginal    incision 
and  drainage  for,  319 
Percussion  wave  in  diagnosis  of  ovarian 

cysts,  445 
Perilymphangitis,  269 
Perimetritis,  273 
Perineal  region,  anatomy  of,  531 
Perineorrhaphy,  529 

for  complete  rupture,  541 
after-treatment  of,  543 


INDEX 


783 


Perineorrhaphy,    for    complete    rupture, 
complicated,  543 
denudation,  541 
introduction  of  sutures,  542 
preparatory  troatmont  in,  541 
retention  of  urine  after,  545 
for  descent  of  uterus,  (3^5 
direction  of  the  tear,  531 
inunediate  ojieration  of,  545 
for  incomplete  rui)ture,  53(5 
after-treatment  in,  540 
suture  material  in,  536 
Perineum,  anatomy  of,  531 

lacerations  of,  complete,  522,  523 
incomplete,  522 
pathological  results  of,  522 
jjrophj'laxis  in,  528 
puerperal,  521 
Periphlebitis,  269 
Perisalpingitis,  273 
Perisalprnx,  255 

Peritoneal  drainage,  contraindications  for 
145 
indicaticns  for,  146 
Peritoneum,  toilet  of,  386 
Peritonitis,  adhesive,  274 
exudative,  274 
pelvic,  273 

diagnosis  of,  277 
differential,  277 
from  ovaritis,  279 
from  tubal  pregnancy,  480 
etiology  of,  273 
pathology  of,  274 
sjTiiptoms  of,  276 
treatment  of,  277,  280 
plastic,  274 
tubercular,  276 
cause  of,  276 
local  signs  of,  277 
pathology  of,  276 
sjonptoms  of,  276 
Pessaries,  adjustment  of,  668 
in  anteflexion  of  uterus,  696 
in  descent  of  uterus,  628 
Emmet's,  669 
function  of,  666 
in  retroflexion  of  uterus,  664 
Smith's,  Albert,  669 
Phantom     tumors     differentiated     from 

ovarian  cysts,  448 
Phosphatic     deposits     in     vesicovaginal 

fistula,  576 
Physiological  periods,  21 
infancv,  21 
maturity,  29 
menopause,  29 
puberty,  22 
senility,  31 
Physometra  differentiated  from  ovarian 

cysts,  452 
Phvsostigmin      sulphate      for      bowels, 

f53 
Pinhole  os  uteri,  225 

Placenta,   formation   of,    in   tubal   preg- 
nancy, 470 


Placentii,    retained,    differentiated   from 

carcinoma  of  uterus,  409 
Plastic-  operations,  105 

peritonitis,  274 
Pneumococcus  a  cause  of  ovaritis,  277 
Polycyst,  429 
Polypoid  endoccrvicitis,  225 

endometritis,  229 
Post -abort  um  endometritis,  230 
Precocious  menstruation,  24 
Pregnancy,  ectopic,  469 
extra-uterine,  469 
myomectomy  during,  401 
normal,  differentiated  from  tubal,  481 
operations  during,  minor,  100 
ovarian,  469 
ovariotomy  during,  463 
tubal,  349,  469 
abortion  in,  473 
diagnosis  of,  479 
differential,  480 

from  hemorrhage,  480 
from  myoma  of  uterus,  368 
from  normal,  481 
from  ovarian  cysts,  450 

tumors,  480 
from  pelvic  cellulitis,  480 

peritonitis,  480 
from  salpingitis,  265 
from  sactosalpinx,  480 
from  uterine  tumors,  480 
etiology  of,  469 
formation  of  amnion  in,  470 
of  chorion  in,  470 
of  decidua  in,  470 
of  placenta  in,  470 
pathology  of,  470 
pelvic    hsematocele    resulting    from, 

476 
prognosis  of,  481 
rupture  in,  473 
sjTiiptoms  of,  476 
treatment  of,  482 
after  abortion,  482 
after  rupture,  482 
early,  before  abortion,  482 

before  rupture,  482 
if  abortion  has  occurred,  483 
if  gestation  has  advanced  beyond 

the  fourth  or  fifth  month,  484 
if  rupture  has  occurred,  483 
vaginal  route  in,  485 
varieties  of,  471 
ampullar,  473 
interstitial,  471 
isthmic,  473 
tuboligamentous,  474 
tubo-uterine,  472 
in  uterine  wall,  469 
Prepuce,  adherent,  510 
hj^pertrophj'  of,  508 
malformations  of,  508 
Probe,  passing  of,  75 

dangers  of,  75 
Proctoscope  in  examination  of  anus,  77 
of  rectum,  77 


784 


INDEX 


Prolapse  of  uterus,  616.    See  Descent  of 

uterus. 
Proneplii-ic  ducts,  development  of,  487 
Pronephros,  development  of,  487 
Protracted  menstruation,  24 
Pruritus  aestivalis,  200 
hiemalis,  200 
of  vulva,  232 
diagnosis  of,  201 
etiology  of,  200 

exciting  causes,  200 
circulatory,  200 
constipation,  200 
mechanical,  200 
parasitic,  200 
secretory,  200 
thermic,  200 
predisposing  causes,  200 
neuropathic,  199 
pathology  of,  201 
prognosis  of,  202 
treatment  of,  202 
surgical,  204 
Psoas  abscess  differentiated  from  pelvic 

cellulitis,  273 
Puberty,  22 

anatomical  basis  of,  22 
care  dm"ing,  27 
education  and,  28 
goitre  of,  27 

phj'siological  features  of,  23 
Puerperium,  diagnosis  of  retroflexion  of 

uterus  in,  653 
Pus  cases,  technique  in,  in  treatment  of 

pelvic  inflammations,  290 
Pyaemia,  33 
Pyelitis,  348 
Pyometra,  232 

differentiated  from  ovarian  cysts,  452 
Pyosalpinx,  259 

differentiated  from  pelvic  cellulitis,  272 
Pyuria,  405 


R 


Radical     abdominal     hysterectomy     in 

carcinoma  of  uterus,  415 
Radium  in   treatment   of   carcinoma  of 

uterus,  42, 
Rectal  conjoined  examination,  62 
Rectocele,  523,  620 

in  lacerations  of  perineum,  526 
Rectovaginal  conjoined  examination,  64 
fistula,  604 
causes  of,  604 
diagnosis  of,  604 
operation  for,  605 
prognosis  of,  604 
Rectum,  examination  of,  77 
proctoscope  in,  77 
sigmoidoscope  in,  77 
Renal  tumors  differentiated  from  ovarian 

cysts,  455 
Retroflexion  of  uterus,  651 
complications  in,  683 


Retroflexion  of  uterus,  congenital,  683 
course  of,  652 
diagnosis  of,  653 

complications  of,  653 
differential,  654 
in  puerperium,  653 
etiology  of,  652 
pathology  of,  652 
symptoms  of,  652 
treatment  of,  655 

methods  of  replacement,  656 
manipulation,  656 

adhesions  and  contractions 

in,  658 
Brandt  method  of,  656 
obstacles  to  replacement,  655 
pessary  in,  adjustment  of,  668 
contraindications     to     use     of, 

664 
function  of,  666 
indications  to  use  of,  664 
retention  by,  664 
replacement     and     retention     of 

uterus,  659 
reposition     in,     manual     ventro- 
vaginal,  659 
ventro-rectovaginal,  663 
abdominal  hysterorrhaphy,  678 

teclmique  of,  680 
Alexander's  operation,  672 
surgical,  Barrett's  operation,  672 
elytroiThaphy  and,  671 
Gilliam  type  of  operation,  672 
perineoiThaphy  and,  671 
removal  of  tumors  and,  671 
retention  bj',  671 
round      ligaments,      crumphng 
upon  themselves,  675 
shortening  of,  intra-abdom- 
inal, 672 
postuterine,  673 
shortening  uterosacral  liga- 
ments, 677 
vaginal  hysterorrhaphy,  682 
Retrolocation  of  uterus,  616 
diagnosis  of,  616 
symptoms  of,  616 
treatment  of,  616 
Retroversion  of  uterus,  648 
comphcations  in,  683 
congenital,  683 
com'se  of,  649 
degrees  of,  651 
description  of,  648  ' 
diagnosis  of,  650 
etiolog>'  of,  648 
prognosis  of,  650 
sjTnptoms  of,  649 

treatment  of,  651,  655.     See  Retro- 
flexion of  uterus,  treatment  of. 
Reynolds  on  Dudley's  operation  for  ante- 
flexion of  uterus,  703 
Rheumatism,  a  cause  of  chronic  metritis, 

248 
Rontgen    skiagrams    in    examination    of 
urkiary  organs,  79 


IXDI'JX 


785 


Rosonmiillor,  organ  of,  (k'vclopiiu'nt    of, 

492 
Round  liganionl,  carcinoma  of,  4GG 
cyst  of,  4Go 

diagnosis  of,  dilTcronlial,  4G5 
from  lu-rnia,  4G5 
from  myoma,  4G5 
treatment  of,  4GG 
fibroma  of,  40') 
hydrocele  of,  4()5 

intra-abdominal    shortening    of,     in 
retroflexion    and    retroversion    of 
uterus,  G72 
myoma  of.  4G5 

diagnosis  of,  difTerential,  465 

from  cysts  of  glands  of  Bar- 
tholin, 465 
from  enlarged  inguinal  glands, 

4G5 
from  omental  hernia,  465 
from  ovarian  hernia,  465 
treatment  of,  4G5 
sarcoma  of,  466 
tumors  of,  465 
Rubber  gloves,  42,  45 
Rubeola,  a  cause  of  atrophic  metritis,  252 
Rudimentarv  development  of  ovaries,  495 

of  tubes,  498 
Rupture  in  tubal  pregnancy,  473 


Sacral  resection,  141 
Sactosalpinx,  259,  2G3 

chi'onic,  vaginal  incision  and  drainage 

for,  317 
differentiated  from  myoma  of  uterus, 
370 
from  tubal  pregnancy,  480 
hemorrhagica,  259 
purulent  a.  259 
serosa,  259 
SalpingectoniA'    in    treatment    of    pelvic 

inflammations,  283 
Salpingitis,  255 
acute,  257,  261 
associated  lesions  of,  268 
chronic,  259,  261 

dj'smenorrha^a  and,  745 
diagnosis  of,  262 
anaesthesia  in,  266 
differential,  265 

from  appendicitis,  265 

from  cystic  ovarian  tumor,  265 

from  displaced  kidney,  266 

spleen,  266 
from  fecal  accumulations,  266 
from  intestinal  tumors,  266 
from  pelvic  cellulitis,  265 
from  solid  tumor  of  tube,  265 
from  tubal  pregnancy,  265 
from  tumors  of  sacrum  and  ilium, 
266 
exploratory  incision  in,  266 
etiology  of,  256 
48 


Salpingites,   eliologv  of,   exciting   causes, 
256 
predisposing  causes,  general,  256 
local,  256 
gonorrlural,  2G3 
infection  in,  routes  of,  in(;oming,  257 

outgoing,  257 
mortality  in.  207 
normal  anatomy  of,  255 
l)at  liology  of,  25() 
])hysi('al  examination  for,  262 
profluens,  749 
prognosis  of,  266 
symptoms  of,  261 

mechanical  disturbances,  262 
menstrual  disturbances,  262 
treatment  of,  267,  280 
tubercular,  263 

diagnosis  of,  differential,  264 
Salpingo-oophorcctomy,  abdominal,  288 
in  treatment  of  pelvic  inflammations, 

284 
vaginal,  298 
Salpingo-stomatomie,  322 
Salt  water  infusion,  drop  method  of,  157 
Saprajmia,  33 

Sarcoma  of  Fallopian  tubes,  465 
of  ovary,  427 
of  round  ligament,  466 
of  urethra,  467 
of  uterus,  422 
butyroides,  423 
diagnosis  of,  423 

differential,  from  carcinoma,  409 
from  mj^oma,  368 
from  ovarian  cysts,  451 
developed  from  myoma,  422 
diffuse,  423 
etiology  of,  422 
fibrosarcoma,  423 
interstitial,  423 
pathology  of,  422 
prognosis  of,  423 
treatment  of,  424 
of  vagina,  357 
of  vulva,  354 

treatment  of,  355 
Sarcomatous  degeneration  of  myoma  of 

uterus,  424 
Scanty  menstruation,  24 
Scarlatina,  a  cause  of  atrophic  metritis 

252 
Schroeder's  operation  for  chronic  endo- 

cervicitis,  223 
Schuchardt's  operation  for  carcinoma  of 

uterus,  420 
Sciatic  nerve,  roots  of,  in  conjoined  exam- 
ination, 65 
Sclerosis  of  ovaries,  748 
Senile  endometritis,  231 

vidvovaginitis,  192 
Senility,  31 

Sepsis  after  abdominal  operations,  157 
general,  158 

treatment  of,  159 
localized,  158 


786 


INDEX 


Sepsis      after      abdominal     operations, 

localized  treatment  of,  158 
Septic  infection,  32 
Septicaemia,  32 
Sex,  differentiation  of,  493 
Shroeder's  method  of  incising  uterus,  118 
Sigmoidoscope  in  examination  of  anus, 
77 
of  rectum,  77 
Silkworm  gut,  sterilization  of,  40 
Silver  nitrate  in  gonorrhoeal  vulvovagi- 
nitis, 187 
Simon's  speculum,  101 
Sims'  position,  correct,  70 
speculum,  68,  101 

self-retaining,  68 
vaginal  plug,  206 
Sinuses,  prevention  of,  163 
Skene's  glands,  183 

gonococcus  in,  327 
inflammation  in,  330 
in  urethritis,  323 
Soap  as  an  antiseptic  agent,  35 
Sodium  carbonate  as  an  antiseptic  agent, 

36 
Sound,  passing  of,  75 

dangers  of,  75 
Speculums,  68 
Simon's,  101 
Sims',  68,  101 
self-retaining,  68 
Sphincter  ani  muscle,  subcutaneous  rup- 
ture of,  545 
Spleen,     displaced,     differentiated    from 

salpingitis,  286 
Sponges  in  abdominal  operations,  132 
Staffordshire  knot,  108 
Stapfer,  celluUtis  of,  270 
Staphylococcus  a  cause  of  ovaritis,  277 
in  metritis,  212 
pyogenes  albus  33 
aureus,  33 
Sterility,  750 
causes  of,  752 

absence  of  virile  spermatozoa,  752 
acquired,  754 

from  inflammatory  disorders,  755 
from  surgical  operations,  754 
atrophy  of  uterus  or  ovaries,  754 
caruncle  of  urethra,  755 
congenital,  753 

complete  or  absolute    acquired  de- 
fects in  reproductive  organs, 
754 
congenital  defects  in  reproduc- 
tive organs,  753 
curettage,  756 
defective     reproductive     organs     in 

woman,  753 
displacements,  753 

stenosis  of  uterus  and,  756 
double  uterus,  753 
elongation   or  shortening   of   cervix, 

753 
excessive  convolutions  of  Fallopian 
tubes,  753 


Sterility,   causes  of,  faulty  general    nu- 
trition in  woman,  752 
gynandry,  753 

incomplete  or  contingent,   acquired 
defects  in  reproductive  organs, 
754 
congenital  defects  in  reproduc- 
tive organs,  753 
indeterminate,  756 
imperforate  or  cribriform  hymen,  753 
kraurosis  of  vulva,  755 
lengthening  of  one  hp  of  cervix,  753 
occlusion  of  tubes  or  uterus,  754 
removal  of  uterus,  tubes,  or  ovaries, 

754 
stenosis  or  atresia,  in  genital  tract, 

753 
vesicovaginal  fistula,  756 
classification  of,  750 
absolute,  751 
complete,  751 
partial,  751 
relative,  751 
definition  of,  750 
diagnosis  of,  757 
due  to  anteflexion  of  uterus,  693 
etiology  of,  751 
prognosis  of,  757 
statistics  of,  750 
treatment  of,  757 
Sterilization  of  arms,  44 
by  boihng,  36 
of  catgut,  40 
of  dressings,  40 
of  gauze,  40 

sponges,  40 
of  hands,  44 
of  linen,  40 
of  silkworm  gut,  40 
by  steam,  36 
of  supplies,  39 
of  water,  40 
Sterilizers,  Arnold's,  under-steam,  37 
Boeckmann's,  over-steam,  36 
high-pressure  steam,  37 
Stomach,     dilated,     differentiated     from 

ovarian  cysts,  448 
Streptococcus  a  cause  of  ovaritis,  277 
pyogenes,  33 
in  metritis,  212 
Sturmdorf  on  causes  of  uterine  hemor- 
rhage, 739 
Stypticin,  373 

in  treatment  of  chronic  endometritis, 
238 
Submucous  myoma  of  uterus,  362 
Subperitoneal  myoma  of  uterus,  363 
Suburethral  abscess  comphcating  urethri- 
tis, 332 
treatment  of,  333 
Superin volution,  251 
Supernumerary  ovaries,  494 

tubes,  496 
Suprarenal  extract,  373 
Supravaginal    hysteromyomectomy    for 
myoma  of  uterus,  384 


IXDEX 


787 


Sutuirs  in  abdominal  section,  buriod,  12'J 
niattu'.ss,  ami  Mit-lu'llo  dips,  130 
ivnunal  of,  109 
Sj'i)hilis   of    ult'ius,    (lilTorentiatecl    from 

oarcinonia,  410 
Syphilitic  vulvovaginitis,  191 
chancre  in,  191 
secondary  lesions  in,  191 
tertiary  lesions  in,  191 


Tami'onade,  93 

in  drainage  of  endometrium,  95 
indications  for,  hemorrhage,  95 

inflammation,  93 
pressiu'c  effect  of,  93 
vehicle    for    introduction    of    medica- 
ments, 93 
Tate's  method  of  treatment  in  inversion 

of  uterus,  721 
Tenaculum  uterine,  103 
Teratomata  of  ovary,  436 
Tobacco  in  treatment  of  prm-itus  \'ulv3e, 

202 
Topical  applications  to  endometrium,  95 
selection  of  cases  for,  96 
to  vagina,  98 
to  \Tilva,  98 
Torsion  in  treatment  of  mvoma  of  uterus, 
375 
of  urethra  for  incontinence  of  m'ine,  759 
of  uterus,  709 
causes  of,  710 
diagnosis  of,  710 
treatment  of,  710 
Toxaemia,  33 

Trachelorrhaphy,  cause  of  ureterovaginal 
fistula,  600  I 

for  laceration  of  cervix,  559 

approximation  in,  563  | 

denudation  in,  563 
disinfection  in,  562 
hemorrhage  in,  564 
immediate  operation,  559 
preparatorj-  treatment  of,  560 

extensive  cj-stic  development 

in,  561 
puncturing  of  cysts  in,  560 
removal  of  cicatricial  plug  in,  563 
secondary  operation,  560 
sutures  in,  564 
Transfusion,  direct,  in  treatment  of  uter- 
ine hemori'hage,  742 
Treatment  of  acute  dilatation  of  stomach, 
160 
of  amenorrhoca,  734 
of  anteflexion  of  uterus,  694 
of  antelocation  of  titerus,  616 
of  anteversion  of  uterus,  688  , 

of  ascent  of  uterus,  616 
Biers'  cupping.  97 
of  carcinoma  of  uterus,  412 
of  vagina,  357 
of  \-ulva,  354 


Treatment  of  chancroidal  vulvovaginitis, 
191 

of  chorio-epithelioma  of  uterus,  426 

of  cin-onic  metritis,  254 

of  congenital  gynatresia,  517 

of  cystitis,  340 

of  cysts  of  vagina,  356 

of  deciduoma  malignum  of  uterus,  426 

of  descent  of  titerus,  ()27 

of  dijihtheritic  vulvovaginitis,  188 

of  dysmenorrlxta,  748 

of  eczema  of  vulva,  197 

of  emphysematous  vaginitis,  196 

of  erj'sipelatous  vulvovaginitis,  188 

of  fibromyoma  of  vagina,  357 

of  vulva,  355 
of  follicular  vulvitis,  195 
of  glandular  vulvitis,  194 
of  gonorrhceal  papilloma  of  vulva,  353 

vulvovaginitis,  186 
of  haematoma  of  vulva,  350,  351 
of  hemorrhage  in  major  operations,  155 
of  hermaplu'odism,  512 
of  hernia  of  ovarj^  728 

of  uterus,  728 
of  hj-jseraesthesia  of  vulva,  205 
of  hysterical  vomiting,  160 
of  incontinence  of  m-ine,  759 
of  inflammation,  176 
intra-uterine,  selection  of  cases  for,  97 
of  inversion  of  uterus,  717,  718 
of  kraurosis  of  ^'ulva,  199 
of  laceration  of  cervix  titeri,  559 
of  lateral  location  of  uterus,  616 
of  lipoma  of  vulva,  355 
local,  90 

hot  vaginal  douche  in,  90 

tamponade  in,  93 

topical  applications  in,  95 
of  mj-cotic  vulvovaginitis,  190 
of  myoma  of  uterus,  372 
of  non-specific  papilloma  of  Analva,  352 
of  obstruction  of  bowels  after  abdomi- 
nal operations,  162 
of  ovaritis,  279,  280 
of  pelvic  cellulit {8,-^73,  280 

inflammations,  280 

peritonitis,  277,  280 
of  premature  menstruation,  730 
preparatory,  of  abdominal  section,  123 

for  minor  operations,  99 
of  prolapse  of  m-ethral  mucosa,  331    ' 
of  prtiritus  of  ^^alva,  202 
of  retroflexion  of  uterus,  655 
of  retrolocation  of  uterus,  616 
of  retroversion  of  uterus,  651,  655 
of  salpingitis,  267,  280 
of  sarcoma  of  uterus,  424 

of  ^tllva,  355 
of  sepsis  after  abdominal  operations, 

158 
of  simple  papilloma  of  Atilva,  352 
of  solid  ttmiors  of  ovarj^  428 
of  sterility,  757 
of  subtu-ethral  abscess,  333 
of  torsion  of  uterus,  710 


788 


INDEX 


Treatment  of  tubal  pregnancy,  482 
of  tubercular  vulvovaginitis,  189 
of  ureterovaginal  fistula,  598 
of  urethi'al  stricture,  331 
of  urethritis,  329 
of  uterine  hemorrhage,  373 
of  vaginismus,  206 
of  varix  of  vulva,  349 
of  vesico-uterine  fistula,  597 
of  vesicovaginal  fistula,  575 
of  vulvovaginitis,  182 
Trendelenburg  position  in  abdominal  sec- 
tion, 121 
substitute  for,  123- 
Trichiasis,  203 
Tubal  pregnancy,  349,  469 
abortion  in,  473 
diagnosis  of,  479 
differential,  480 

from  hemorrhage,  480 
from  normal,  481 
from  ovarian  cysts,  450 

tumors,  480 
from  pelvic  cellulitis,  480 

peritonitis,  480 
from  salpingitis,  265 
from  sactosalpinx,  480 
from  uterine  tumors,  480 
etiology  of,  469 
formation  of  amnion  in,  470 
of  chorion  in,  470 
of  decidua  in,  470 
of  placenta  in,  470 
pathology  of,  470 
pelvic   hsematocele,    resulting   from, 

476 
prognosis  of,  481 
rupture  in,  473 
symptoms  of,  476 
treatment  of,  482 
after  abortion,  482 
after  ruptm-e,  482 
early,  before  abortion,  482 

before  rupture,  482 
if  abortion  has  occurred,  483 
if  gestation  has  advanced  beyond 

the  fourth  or  fifth  month,  484 
if  rupture  has  occurred,  483 
vaginal  route  in,  485 
viability  of  child  at  term,  481 
varieties  of,  471 
ampullar,  473 
interstitial,  471 
isthmic,  473 
Tubercle  bacillus  a  cause  of  ovaritis,  277 
Tubercular  cystitis,  340 
diagnosis  of,  340 
peritonitis,  276 
cause  of,  276 
local  signs  of,  277 
pathology  of,  276 
symptoms  of,  276 
salpingitis,  263,  464 
suppuration,  vaginal  incision  and  drain- 
age for,  319 
vulvovaginitis,  188 


Tubercular  vulvovaginitis,  treatment  of, 

189 
Tuberculosis,  bacillus  of,  34 

of    uterus,    differentiated    from    carci- 
noma, 410 
of  vulva,  356 
Tubohgamentous  pregnancy,  474 
Tubo-ovarian  abscess,  440 

cyst,  260,,  440 
Tubo-uterine  pregnancy,  472 
Tubular  drainage,  146 
Tumors,  349 
of  bladder,  468 
diagnosis  of,  468 

differential,  468 
mahgnant  disease  and,  468 
of  broad  hgament,  465 
cystic  ovarian  differentiated  from  sal- 
pingitis, 265 
of  Fallopian  tubes,  464 
intestinal,   differentiated   from   salpin- 
gitis, 266 
intramural,  380 

ovarian,  differentiated  from  tubal  preg- 
nancy, 480 
pedunculated  subperitoneal,  379 
phantom,  differentiated  from  ovarian 

cysts,  448 
renal,  differentiated  from  ovarian  cysts, 

455 
of  round  hgament,  465 
of  sacrum  and  ihum  differentiated  from 

salpingitis,  266 
sohd,  of  ovary,  427 
diagnosis  of,  427 
treatment  of,  428 
of  urethra,  466 
of  urinary  organs,  464 
uterine,  358 

a  cause  of  hemorrhage,  737 
differentiated  from  tubal  pregnancy, 
480 
of  vagina,  349 
of  vulva,  349 
fatty,  355 
Tympanites,  differentiated  from  ovarian 

cysts,  448 
Typhoid  bacillus  a  cause  of  ovaritis,  277 


U 


Ulceration  of  cervix  uteri,  556 

Ulcerative  cystitis,  336 

Uraemia,  405 

Ureter,  exploration  of,  80 

injury  to,  in  ovariotomy,  462 
insertion  of,  into  bladder,  295 
lateral  anastomosis  of,  295 
wounds  of,  in  abdominal  section,  294 
in  vaginal  hysterectomj^,  602 

Ureteral  fistula  to  external  surface,  295 

Ureterocystostomy  by  bladder  divertic- 
ulum, 295 

Ureterorrhaphy,  294 

for  division,  complete,  of  ureter,  295 


IXDEX 


"89 


Ureterorrhaphj',   for  division,  coniiJetc, 
insertion  into  bladder,  295 
lateral  anastomosis,  295 
incomplete,  of  ureter,  294 
partial  transverse,  294 
Ureterovaginal  fistula,  597 
acquired,  597 
causes  of,  598 
congenital,  597 
diagnosis  of,  598 
traumatic,  result  of  trachelorrhaphy, 

600 
treatment  of,  598 

Dudley's  clamp  operation  in,  598 
Urethra,  advancing  of,  for  incontinence 
of  urine,  759 
atresia  of,  505 
carcinoma  of,  467 

caruncle  of,  a  cause  of  sterility,  755 
dilatation  of,  in  treatment  of  cystitis, 

345 
mucous  polj-pi  of,  467 
sarcoma  of,  467 

torsion  of,  for  incontinence  of  m-ine,  759 
tumors  of,  466 
warts  of,  467 
Urethral  caruncle,  466 

diagnosis      of,      differential,      from 

Skene's  glands,  467 
treatment  of,  467 
cn.-pts.  inflammation  of,  192 
mucosa,     prolapse     of,     compUcating 
urethi-itis,  331 
treatment  of,  331 
stricture,  treatment  of,  331 
Urethritis,  326 

compUcated   bj'  prolapse   of  urethral 
mucosa,  331 
treatment  of,  331 
by  suburethral  abscess,  332 
treatment  of,  333 
compUcations  of,  331 
diagnosis  of,  327 

from  urethral  camncle,  327 
etiology'  of,  326 
gonorrhceal,  326 
pathologj'  of,  326 
sjTnptoms  of,  327 
treatment  of,  329 
Urethroscopj-  in  examination  of  urinary 

organs,  80 
Urethrovaginal  fistula,  597 
Urinahsis,    in    examination    of    m-inary 

organs,  78 
Urinarv'  fistula   after   abdominal  opera- 
tions, 163 
organs,  examination  of,  77 
catheterization  in,  80 
cj'stoscop}'  in,  SO 
cyhndrical,  SO 
dorsal  position  in,  81 
electrical,  S3 

knee-breast  position  in,  83 
value  of,  86 
inspection  in,  79 
palpation  in,  79 


Urinary  orgaris,  examination  of,  percus- 
sion in,  79 
Rontgen  skiagram  in,  79 
ureteral  catheterization  in,   value 
of,  86 
exploration  in,  80 
lu-ethroscopy  in,  80 
m-inalj'sis  in,  78 
timiors  of,  464 
Urine,  incontinence  of,  758 
active,  758 
passive,  758 
treatment  of,  759 

by  advancing  of  urethra,  759 
Huir.melfarb's  method,  759 
Pawlik's  method,  759 
by  Dudley's  operation,  763 
by  injection  of  paraffin,  759 
by  ma&sage  and  electricity,  759 
by  torsion  of  urethra,  759 
residual,  in  cj-stocele,  526 
Urogenital  sinus,   development   of,   491, 

493 
Urotropin  for  cystitis,  343 

for  gonorrhceal  urethritis,  330 
Uterine  appendages,  inflammation  of,  261 
operations  on,  284 
removal  of,  effects  of,  284 

technique  of,  in  adhesions,  292 
in  hemorrhage,  293 
in  intestinal  opening,  293 
in  pus  cases,  290 
in  wounds  of  ureter,  294 
cavity,  elongation  of,  in  myoma,  367 
discharge  in  carcinoma,  405 
in  myoma  of  uterus,  366 
hemorrhage,  736 

causes  of,  displacements,  737 
foreign  bodies,  739 
inflammations,  736 
extra-uterine,  737 
uterine,  736 
systemic  disorders,  738 
tumors,  737 
uterkie  moles,  738 
cvstic,  738 
fleshy,  738 
hj'datiform,  739 
visceral  diseases,  738 
diagnosis  of,  740 
during  maturity,  741 

menopause,  741 
etiologj'  of,  736 
of  girls,  740 
treatment  of,  373,  741 
Boldt's  remedy  for,  741 
infusion  of  normal  salt   solution, 

373 
injection  of  beef  blood  serum,  374 
subcutaneous,  of  human  blood, 
374 
intra-uterine  stj-ptics,  373 

tamponade,  373 
local,  742 
medication,  373 
sm"gical,  742 


790 


INDEX 


Uterine  hemorrhage,   treatment  of,   sys- 
temic, 741 
transfusion  of  human  blood,  374 
profuse  leucorrhoea,   from  uterine  in- 
flammations, 736 
tenaculum,  103 

tumors  differentiated  from  tubal  preg- 
nancy, 480 
Uterosacral  hgaments,  shortening  of,  in 
retroflexion  of  uterus,  677 
in  retroversion  of  uterus,  677 
Uterus,  accessory,  497 
anatomy  of,  207 

cervical  portion,  208 
corporeal  portion,  207 
bloodvessels,  208 
endometrium,  207 
glands  of  corpus  uteri,  207 
lymphatics,  208 
nerves,  208 
anteflexion  of,  687 
acquired,  690 

cervix  in  labor  after  Dudley's  opera- 
tion for,  709 
classification  of,  690 
complications  of,  691 
congenital,  690 
course  of,  691 
developmental,  690 
diagnosis  of,  693 
etiology  of,  690 
pathological,  689 
pathology  of,  690 
symptoms  of,  691 
urethi'al,  691 
uterine,  692 

dysmenorrhoea,  693 
endometritis,  693 
sterility,  693 
vesical,  691 
treatment  of,  694 

complications  of,  695 
by  Dudley's  operation,  700 
by  electricity,  697 
by  forcible  dilatation,  697 
by  local  pelvic  massage,  696 
mechanical  indications  for,  695 
by  pessary,  698 

by    posterior    division    of    cervix 
uteri,  700 
antelocation  of,  616 
diagnosis  of,  616 
symptoms  of,  616 
treatment  of,  616 
anteversion  of,  687 
diagnosis  of,  688 
etiology  of,  687 
pathological,  687 
prognosis  of,  688 
symptoms  of,  687 
treatment  of,  688 
ascent  of,  615 
diagnosis  of,  616 
symptoms  of,  616 
treatment  of,  616 
bicornate,  497 


Uterus,  carcinoma  of,  403 
adenocarcinoma,  403 
advanced,  407 
cylindrical-cell,  403 
diagnosis  of,  406 

clinical  history  in,  406 
differential,  409 

from  arteripsclerosis,  411 

from  chronic  endocervicitis,  222 

metritis,  410 
from  endocervicitis,  409 
from  endometritis,  410 
from  endothelioma,  411 
from  hypertrophy  of  cervix,  409 
from  ichthyosis  uteri,  410 
from  laceration  of  cervix,  411 
from  myoma,  368,  409 
from  ovarian  cysts,  451 
from  retained  placenta,  409 
from  sarcoma,  409 
from  syphilis,  410 
from  tuberculosis,  410 
of  extension  of,  408 
to  bladder,  408 
to  glands,  408 
by  metastasis,  408 
to  parametria,  408 
to  rectum,  408 
to  vagina,  408 
physical  signs  in,  406 
recurrence  of,  after  removal,  408 
epithelioma,  403 
etiology  of,  403 
extent  of,  404 
gland,  403 
pathology  of,  403 
pavement-cell,  403 
prognosis  of,  411 
squamous,  403 
symptoms  of,  404- 
cachexia,  406 
hemorrhage,  405 
pain,  405 

uterine  discharge,  405 
visceral  disorders,  405 
treatment  of,  412 
general,  421 
hysterectomy  in,  413 
ignihysterectomy,  417 
mortahty  of,  419 
paravaginal,  413 
radical  abdominal,  415 
recurrence  after,  420 
operation  of  election  in,  420 
pafliative,  421 
radium  in,  421 
.T-ray  in,  421 
of  child,  22 

chorio-epithehoma  of,  425 
diagnosis  of,  426 
etiology  of,  425 
pathology  of,  425 
prognosis  of,  426 
symptoms  of,  426 
treatment  of,  426 
curettage  of,  118 


IXDEX 


m 


Uterus,  curettage  of,  technique  of,  120 
deciduoiiui  aclenoinato.suni  of,  425 
carcinoinatosuin  of,  125 
malignuiu  of,  425 
diagnosis  of,  42G 

microscopic  examination,  426 
physical  examination,  426 
etiology  of,  425 
patliology  of,  425 
])rognosis  of,  420 
symptoms  of,  426 
treatment  of,  426 
sarcomatosum  of,  425 
denudation  of,  106 
descent  of,  616 
course  of,  625 
diagnosis  of,  625 

ditTerential,  625 
enteroptosis  as  complication  of,  646 
etiology  of,  617 
mechanism  of,  617 
pathology  of,  623 
prophylaxis  of,  626 
symptoms  of,  625 
treatment  of,  627  _ 
non-surgical,  627 

general  and  local  measures  in, 

627 
hygiene  in,  627 
pessaries  in,  628 
surgical,  628 

abdominal    hysterorrhaphy    in, 

646 
Alexander's  operation  in,  646 
comparison     of     eh-trorrhaphy 

and  hysterectomy,  645 
eMrorrhaphy  in,  634 

"contraindication  to,  635 
hysterectomy  in,  628 
perineoiThaphy  in,  635 
plastic  operations  in,  630 
dilatation  of,  76,  109  _ 

diverging  instruments  in,  76,  114 
extent  of,  115 
forcible,  danger  of,  116 
technique  of,  116      _ 
graduated  bougies  in,  76,  114 
tents  in,  76,  109 

with  intra-uterine  medication.  111 
water  dilators  in.  76 
displacement  of,  607 
definition  of,  611 
diagnosis  of,  612 

from  myoma,  369 
mal-locations,  611,  615 
malpositions,  612,  648 
nomenclatvu-e  of,  611 
s\'mptoms  of,  612 
doiible,  497,  514 

a  cause  of  sterility,  753 
endothehoma  of,  411 
hemorrhage  of,  treatment  of,  tampon 

in,  95 
hernia  of,  728 
diagnosis  of,  728 
treatment  of,  728 


terus,  idithyosis  of,  differentiated  from 

carcinoma,  410 
incision  of,  116 

Dudley's  method,  118 
Slu-oeder's  method,  118 
infantile,  497 

arbor  vita'  arrangement  of,  23 
inflannnation  of.    See  Metritis, 
inversion  of,  711 
anatomy  of,  714 
diagnosis  of,  715 
etiology  of,  711 
mechanism  of,  714 
pathology  of,  714 
prognosis  of,  717 

chronic,  717 
symptoms  of,  715 
treatment  of,  acute,  717 
chi'onic,  718 

by  colpeurynter,  721 

by  elastic  pressure,  721 

by  hyst  erect omj',  723 

by  incision,  723 

manual,  Emmet's  method,  720 

Tate's  method,  721 
methods  of,  718 
obstacles  to,  718 
preparatory,  720 
by  water-bag,  721   - 
inverted,  369 
lateral  location  of,  616 
diagnosis  of,  616 
sjTiiptoms  of,  616 
treatment  of,  616 
malformation  of,  496 
mucous  poljTDS  of,  229 
myoma  of,  358 

classification  of,  361 
cervical,  364 
intramural,  361 
submucous,  362 
pedunculated,  362 
primarily,  362 
secondarily,  362 
subperitoneal,  363 
intraUgamentous,  363 
diagnosis  of,  366 

bj'  conjoined  examination.  366 
exploration  by  sound,  367 
intra-uterine,  367 
differential,  367 

from  carcinoma,  368 

from  chronic  metritis,  368 

complicating  pregnancy,  368 

from  cj'sts,  370 

from   displacements   of   uterus, 

369 
from  floating  kidney,  370 
from  incomplete  abortion,  369 
from  intra-uterine  pregnancy. 

367 
from  ovarian  cysts,  450 
from  ovary,  369 
from    pelvic    inflammatoiy    in- 
filtrations, 369 
from  sactosalpinx,  370 


792 


INDEX 


Uterus,  myoma  of,   diagnosis  of,  differ- 
ential, from  sarcoma,  368 
from  tubal  pregnancy,  368 
by  inspection  and  palpation,  366 
z-ray  in,  367,  368,  370 
•^     Dudley's  incision  in,  377 
etiology  of,  358 
intraligamentous,  382 
natural  cure  of,  371 
pathology  of,  358 
prognosis  of,  371 

after  operation  for,  401 
non-operative,  371 
operative,  371 
sarcomatous  degeneration  of,  424 
secondary  changes  of,  359 
calcification,  359 
fatty  degeneration,  359 
gangrene,  359 
malignant  changes,  360 
mucoid  degeneration,  359 
septic  infection,  360 
symptoms  of,  364 
congestion,  364 
hemorrhage,  364 
miscellaneous,  388 
pain  and  discomfort,  365 
pressure,  372 
treatment  of,  372 

abdominal  myomectomy  in,  378 

drainage  in,  380 
electrolysis  in,  372 
hysteromyomectomy  in,  complete 
abdominal,  383 
technique  of,  383 
supravaginal,  384 
technique  of,  384 
non-surgical,  372 

manipulation,  372 
surgical,  374 

palliative  operations,  375 
radical    abdominal    operations, 
378 
vaginal  operations,  375 
torsion  in,  375 

vaginal  hysterectomy  in,  375 
enucleation  and  morcellation  in, 
375 
x-ray  in,'  372 
normal  position  of,  608 
movements  of,  610 
supports  of,  611 
premature  development  of,  501 
prolapse  of,  616.     See  Uterus,  descent 

of. 
removal  of,  advisability  of,  285 
retroflexion  of,  651 
complications  in,  683 
congenital,  683 
course  of,  652 
diagnosis  of,  653 

comphcations  of,  653 
differential,  654 
in  puerperium,  653 
etiology  of,  652 
pathology  of,  652 


Uterus,  retroflexion  of,  symptoms  of,  652 
treatment  of,  655 

method  of  replacement,  656 
by  manipulation,  656 

adhesions  and  contractions 

in,  658 
Brandt's  method  of,  656 
obstacles  to  replacement,  655 
pessary  in,  adjustment  of,  668 
contraindications  to  use  of,  664 
function  of,  666 
indications  to  use  of,  664 
retention  by,  664 
replacement     and     retention     of 

uterus,  659 
reposition     in,     manual     ventro- 
rectovaginal,  663 
ventrovaginal,  659 
surgical,       abdominal      hysteror- 
rhaphy  in,  678 
technique  of,  680 
Alexander's  operation,  672 
elytrorrhaphy  and,  671 
Gilliam  type  of  operation,  672 
perineorrhaphy  and,  671 
removal  of  tumors  and,  671 
retention  by,  671 
roimd  hgaments,  crumpling  up- 
on themselves,  675 
shortening  of,  intra-abdomi- 
nal, 672 
postuterine,  673 
shortening  uterosacral  ligaments, 

677 
vaginal  hysterorrhaphy,  682 
retrolocation  of,  616 
diagnosis  of,  616 
symptoms  of,  616 
treatment  of,  616 
retroversion  of,  648 
complications  in,  683 
congenital,  683 
course  of,  649 
degrees  of,  651 
description  of,  648 
diagnosis  of,  650 
etiology  of,  648 
prognosis  of,  650 
symptoms  of,  649 

treatment  of,  651,  655.    See  Uterus, 
retroflexion  of,  treatment  of. 
sarcoma  of,  422 
butyroides,  423 
diagnosis  of,  423 

differential,  from  myoma,  368 
from  ovarian  cysts,  451 
diffuse,  423 
etiology  of,  422 
fibrosarcoma,  423 
interstitial,  423 
pathology  of,  422 
prognosis  of,  423 
treatment  of,  424 
senile  changes  in,  at  menopause,  30 
septus,  499 
torsion  of,  709 


INDEX 


Jd'6 


UteriiP,  torsion  of,  causes  of,  710 

diagnosis  of,  710 

tiTiitnicnt  of,  710 
tiunors  of   o5S 
unicornis,  501 


Vagina,  anomalios  of,  503 

artificial,  for  lucniatonictra,  518 
asi)iration  of  liytlrosali)inx  through,  317 

techni(iuc  of,  317 
atresia  of,  505 

inilannnatory,  503 
carcinoma  of,  357 

treatment  of,  357 
complete  absence  of,  502 
cysts  of,  356 

diagnosis  of,  ditTercntial,  356 
treatment  of,  356 
disinfection  of,  378 
double,  514 
fibromyoma  of,  357 
treatment  of,  357 
henioirhage  from,  treatment  of,  tam- 
pon in,  95 
injuries  of,  521 
maKormations  of,  501 
preparation  of,  for  aseptic  operations, 

47 
sarcoma  of,  357 

senile  changes  in,  at  menopause,  30 
septa,  502 

topical  applications  to,  98 
tumors  of,  349 
Vaginal  conjoined  examination,  59 

cystotomy  in  treatment  of  cystitis,  345 
douche,  90 
action  of,  92 

as  cleansing  agent,  92 
as  vascular  stimulant,  92 
contraindications  to,  92 
indications  for,  92 
drainage,  150 
enucleation  in  treatment  of  myoma  of 

uterus,  375 
hysterectomy,  299 
accidents  of,  301 
after-treatment  of,  316 
with    hiemostasis    by    forcipressure, 
300 
advantages  of,  316 
by  ligature,  299 
advantages  of,  316 
in  treatment  of  myoma  of  uterus,  375 
wounding  of  ureter  in,  602 
hysterorrhaphy,  682 
incision  and  drainage,  for  acute  pelvic 
suppuration,  319 
for  chronic  sactosalpinx,  317 
as  a  temporizing  measiu'e,  321 
for  tubercular  suppuration,  319 
morcellation  in  treatment  of  myoma 

of  uterus,  375 
ovariotomj',  463 


Vaginal  salpingo-oophorectomy,  298 
section,  140 

combined  with  abdominal,  316 
in  treatment  of  jx-lvic  inflammations, 
296 
advantages  of,  321 
Vaginismus,  205 

clinical  course  of,  205 
etiology  of,  205 
treatment  of,  206 
Vaginitis,  177.    See  Vulvovaginitis, 
dissecting,  188 
emphysematous,  196 

treatment  of,  196 
superHcial,  191 
Varix  of  vulva,  349 
diagnosis  of,  349 
pathological  appearance  of,  349 
treatment  of,  349 
Vas  deferens,  492 

Ventral   hernia   after   abdominal   opera- 
tions, 163 
Ventro-rectovaginal  reposition  of  uterus, 

663 
Ventrovaginal  reposition  of  uterus,  659 
Vesical  catarrh,  405 

comphcations  from  abdominal  drain- 
age, 143 
Vesico-uterine  fistula,  597 
diagnosis  of,  597 
treatment  of,  597 
Vesicovaginal  fistula,  573 
cause  of  cystitis,  574 

of  sterility,  756 
course  of,  574 
diagnosis  of,  574 
differentiated    from    ureterovaginal 

fistula,  574 
etiology  of,  573 
prognosis  of,  575 
symptoms  of,  574 
treatment  of,  prophylactic,  575 
surgical,  576 

atypical  operations,  589 
Kelly's  operation,  596 
kolpokleisis,  590 
loss  of  entu'e  vesicovaginal  sep- 
tum, 589 
operation  for  closing,  581 
after-treatment  of,  587 
application    of    sutures   in, 

586 
choice  of  speculum,  582 
denudation  in,  584 
direction   of    line  of   union 

in,  583 
method  of  operation,  582 
preparatory  treatment,  582 
preparatory,  576 
cj'stitis  in,  577 
direction      and      manner      of 

closure,  577 
phosphatic  deposits  in,  576 
stone  in  bladder  in,  577 
Virchow,  erysipelas  malignum  internum 
of,  269,  273 


794 


INDEX 


Vulsella  forceps,  101 
Vulva,  carcinoma  of,  353 
cylindrical-cell,  353 
diagnosis  of,  354 

positive,  354 
etiology  of,  353 
pathology  of,  353 
pavement-cell,  353 
treatment  of,  354 
condyloma  of,  351 
cysts  of,  355 
eczema  of,  197 

treatment  of,  197 
elephantiasis  of,  350 
diagnosis  of,  350 

differential,  351 
etiology  of,  350 

filaria  sanguinis  hominis,  350 
pathology  of,  350 
treatment  of,  351 
enchondroma  of,  353 
fibromyoma  of,  355 
treatment  of,  355 
garrulity  of,  528 
hsematoma  of,  350 
herpes  of,  198 
hyperaesthesia  of,  204 

treatment  of,  205 
infantile,  507 
injuries  of,  521 
kraurosis  of,  198 

a  cause  of  sterility,  755 
diagnosis  of,  199 
pathology  of,  198 
symptoms  of,  199 
treatment  of,  199 

Longyear's  operation,  199 
lipoma  of,  355 

treatment  of,  355 
lupus  of,  356 
malformations  of,  503 
neuroma  of,  356 
pachydermia  of,  350 
papilloma  of,  351 
gonorrhceal,  352 

treatment  of,  353 
non-specific,  352 

treatment  of,  352 
simple,  352 

treatment  of,  352 
syphilitic  flat,  353 
pruritus  of,  diagnosis  of,  201 
etiology  of,  200 

exciting  causes,  200 
circulatory,  200 
constipation,  200 
mechanical,  200 
parasitic,  200 
secretory,  200 
thermic,  200 
predisposing  causes,  200 
neuropathic,  199 
pathology  of,  201 
prognosis  of,  202 
treatment  of,  202 
surgical,  204 


Vulva,  sarcoma  of,  354 

treatment  of,  355 
superficial  atresia  of,  506 
topical  applications  to,  98 
tuberculosis  of,  356 
tumors  of,  349 

fatty,  355 
varix  of,  349 

cause  of,  349 

diagnosis  of,  349 

pathological  appearance  of,  349 

treatment  of,  349 
warts  of,  351 
Vulvitis,  177.    See  Vulvovaginitis, 
diabetic,  189 
folhcular,  194 

treatment  of,  195 
glandular,  192 

diagnosis  of,  194 

treatment  of,  194 
granular,  183 
superficial,  191 
tubercular,  189 
Vulvitus  pruriginosa,  204 
Vulvovaginal  glands,  183 

inflammation  of,  192 
Vulvovaginitis,  177 

anatomical  forms  of,  191 
chancroidal,  191 

treatment  of,  191 
chronic,  181 
diagnosis  of,  181 
diphtheritic,  188 

treatment  of,  188 
erysipelatous,  187 

erythematous,  187 

gangrenous,  187 

treatment  of,  188 

vesicular,  187 
etiology  of,  177 

exciting  causes,  178 

favoring  conditions,  177 
granular,  179 
gonorrhoea],  183 

diagnosis  of,  184 

prognosis  of,  184 

treatment  of,  186 
prophylactic,  186 
leucorrhea  in,  179 
mycotic,  189 

clinical  history  of,  189 

diagnosis  of,  189 

etiology  of,  189 

prognosis  of,  190 

symptoms  of,  189 

treatment  of,  190 
pathology  of,  178 
prognosis  of,  181 
pseudodiphtheric,  188 
senile,  192 
symptoms  of,  180 
syphilitic,  191 

chancre  in,  191 

secondary  lesions  in,  191 

tertiary  lesions  in,  191 
treatment  of,  182 


IXDEX 


r9o 


Vulvovaginitis,  treatment  of,   acute,  1.S2 
chronic,  182 
l)roi)hylactic,  182 
tubercular,   188 
treatment  of,  189 


W 


Wadswortm  on   Dudley's  operation  for 

anteflexion  of  uterus,  703 
Waist  constriction,  Kio 
AN'aldever,  ^■ello\v  body  of,  development 

of,  492 
A\ "arts  of  m'ethra,  467 

of  vulva.    See  Papilloma  of  vulva. 


Water,  stcrili/ation  of,  40 

^^■oU^an  body,  429,  4M\ 

dcvelopiiient  of,  487,  492 
ducts,  development  of,  487,  492 
ritlge,  development  of,  486 


X-ray    in    treatment   of    carcinoma   of 
uterus,  421 


Zinc  sulphate  for  mycotic  vulvovaginitis, 
190 


\ 


^^ 


v 


\ 


>i 


.V 


WG^ 


\ov 


\^\3 


ra-x^V 


A. 


n 


Wn'\.ovV>\.4.>   »1^  \vao< 


^ 


^.  A 


r 


>\^  MT'^t.^^Aott^ 


